Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access) - 36194FL0160003 Health Insurance Plan

Health First Commercial Plans, Inc. health insurance plan with the Plan ID 36194FL0160003. The plan is called Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.90% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.10% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 36194FL0160003
Health Insurance Plan Year 2023
State Florida
Health Insurance Issuer Health First Commercial Plans, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 36194FL0160003-00
Provider Network(s) ['FLN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Florida All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 36194FL0160003-00

Standard On Exchange Plan - 36194FL0160003-01

Open to Indians below 300% FPL - 36194FL0160003-02

Open to Indians above 300% FPL - 36194FL0160003-03

Last Plan Update Date Thu, 09 Mar 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access) Health Insurance Plan, 36194FL0160003-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental

Coverage is limited to care and stabilization treatment rendered within 62 calendar days of an accidental dental injury.

YES

20.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

20.00% Coinsurance after deductible

100.00%
Anesthesia Services for Dental Care

Includes general anesthesia and hospitalization services in connection with dental treatment provided in a hospital or ambulatory surgical center.

YES

20.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child

Covered up through the end of the birth month in which the covered person reaches age nineteen (19).

YES

$0.00

100.00%
Cardiac and Pulmonary Rehabilitation

Limit: 36.0 Days per Lifetime

YES

20.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

20.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 26.0 Visit(s) per Year

YES

$50.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

20.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

Covered up through the end of the birth month in which the covered person reaches age nineteen (19). Basic and major dental care and orthodontic services.

YES

$0.00

100.00%
Diabetes Education

In order to be covered, diabetes outpatient self-management training and educational services must be provided under the direct supervision of a certified diabetes educator or board certified physician specializing in endocrinology.

YES

$0.00

100.00%
Dialysis
YES

20.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Exclusions: Items that are primarily for convenience or comfort and items available over-the-counter are excluded. The replacement of equipment is also excluded, unless it is non-functional and not practically repairable.

YES

20.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Enteral/Parenteral and Oral Nutrition Therapy
YES

20.00% Coinsurance after deductible

100.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Covered up through the end of the birth month in which the covered person reaches age nineteen (19).

YES

$0.00

100.00%
Gender Affirming Care
NO
Generic Drugs

Preferred Generic Drugs: $2 copay for 30 days' supply.

YES

$10.00

100.00%
Genetic Testing Lab Services

BRCA Analysis to determine a woman's genetic risk for breast and ovarian cancer is covered as a preventive benefit when medical necessity criteria are met and authorized in advance by the health plan.

YES

20.00% Coinsurance after deductible

100.00%
Habilitation Services

Limit: 35.0 Visit(s) per Year

Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Combined limit for all outpatient habilitative physical, occupational and speech therapy. Limit applies per condition.

YES

20.00% Coinsurance after deductible

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 60.0 Visit(s) per Year

One date of service is equal to one visit.

YES

20.00% Coinsurance after deductible

100.00%
Hospice Services

Exclusions: Covered hospice services do not include bereavement counseling, pastoral counseling, financial or legal counseling or custodial care.

YES

20.00% Coinsurance after deductible

100.00%
Hyperbaric Oxygen Therapy
YES

20.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)

Cost-share applies per visit, per type

YES

20.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy

Includes chemotherapy, infusions, therapeutic injections, allergy immunotherapy, and other medications ordered and administered by a provider.

YES

20.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

Coverage for inpatient rehabilitation services are limited to 21 days per calendar year.

YES

20.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

20.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child

Covered up through the end of the birth month in which the covered person reaches age nineteen (19).

YES

$0.00

100.00%
Mental/Behavioral Health Inpatient Services
YES

20.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

20.00% Coinsurance after deductible

100.00%
Mental Health Office Visit

Virtual Health provided as a means to receive this benefit.

YES

$20.00

100.00%
Non-Preferred Brand Drugs
YES

$75.00

100.00%
Nutritional Counseling
YES

$0.00

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Covered up through the end of the birth month in which the covered person reaches age nineteen (19).

YES

$0.00

100.00%
Osteoporosis Treatment

Treatment provided at a primary care physician's office will be subject to the Primary Care Visit cost-share.

YES

$50.00

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)

Specialist Visit cost-share will apply if visit is in a specialist's office.

YES

$20.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

20.00% Coinsurance after deductible

100.00%
Outpatient Observation
YES

20.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 35.0 Visit(s) per Year

Combined limit for all outpatient rehabilitative physical, occupational and speech therapy. Limit applies per condition.

YES

20.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Partial Hospitalization

A structured program of active treatment for psychiatric care that is more intense than the care performed in a physician?s or therapist?s office.

YES

20.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$40.00

100.00%
Preferred Generic Drugs
YES

$2.00

100.00%
Prenatal and Postnatal Care

Visits 16+ and visits with a perinatologist are subject to the Specialist Visit cost-share. Birthing classes are covered at $0 copay.

YES

$0.00

100.00%
Preventive Care/Screening/Immunization

Limited to services recommended with an "A" or "B" rating by the U.S. Preventive Services Task Force (USPSTF), immunizations recommended for routine use by the Centers for Disease Control and Prevention (CDC), and services listed in guidelines of the Health Resources and Services Administration (HRSA) for women and children.

YES

$0.00

100.00%
Primary Care Visit to Treat an Injury or Illness

Virtual Health provided as a means to receive this benefit.

YES

$20.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices

Covered prosthetic devices (except cardiac pacemakers and prosthetic devices incident to a mastectomy) are limited to the first such permanent prosthesis, including the first temporary prosthesis if necessary, prescribed for each condition. Coverage is provided for necessary replacement of a prosthetic device owned by the enrollee when due to irreparable damage, wear, a change in the enrollee's condition, or when necessitated due to growth of a child.

YES

20.00% Coinsurance after deductible

100.00%
Radiation
YES

20.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Any cosmetic reconstructive surgery is exclused. Surgery performed outpatient is subject to the Outpatient Facility Fee and Outpatient Surgery Physician/Surgical Services cost-share.

YES

20.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 35.0 Visit(s) per Year

Combined limit for all outpatient rehabilitative physical, occupational and speech therapy. Limit applies per condition.

YES

20.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 35.0 Visit(s) per Year

Combined limit for all outpatient rehabilitative physical, occupational and speech therapy. Limit applies per condition.

YES

20.00% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

Covered up through the end of the birth month in which the covered person reaches age nineteen (19).

YES

$0.00

100.00%
Routine Foot Care

Routine foot care, including any service or supply in connection with foot care, is only covered when medically necessary.

YES

$50.00

100.00%
Skilled Nursing Facility

Limit: 60.0 Days per Year

YES

20.00% Coinsurance after deductible

100.00%
Specialist Visit

Virtual Health provided as a means to receive this benefit.

YES

$50.00

100.00%
Specialty Drugs

Coverage is limited to 30-day supply from preferred specialty pharmacy.

YES

30.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

20.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

20.00% Coinsurance after deductible

100.00%
Substance Abuse Office Visit

Virtual Health provided as a means to receive this benefit.

YES

$20.00

100.00%
Transplant

Includes bone marrow transplant

YES

20.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Limit: 1.0 Item(s) per 6 Months

One splint in a six (6) month period is covered, unless a more frequent replacement is determined to be medically necessary. Splints are subject to the Durable Medical Equipment cost-share. Medically necessary outpatient surgical procedures are subject to the Outpatient Facility Fee and Outpatient Surgery Physician/Surgical Services cost-share.

YES

20.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities

Virtual Health provided as a means to receive this benefit. Virtual Urgent Care copay $30.

YES

$60.00

$60.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

$0.00

100.00%
X-rays and Diagnostic Imaging

Cost-share applies per visit, per type

YES

20.00% Coinsurance after deductible

100.00%

Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access) Health Insurance Plan Variant 36194FL0160003-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.809011669
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Gold Off Exchange Plan
Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 30.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Drug EHB Deductible, In Network (Tier 1), Individual $0
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Out of Network, Individual Not Applicable
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID FLF001
Formulary URL URL
HIOS Product ID 36194FL016
Import Date 3/9/2023 1:02
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 36194
Issuer Marketplace Marketing Name Health First Commercial Plans, Inc.
Market Coverage Individual
Medical Drug Deductibles Integrated No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 20.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $3200 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $1600 per person
Medical EHB Deductible, In Network (Tier 1), Individual $1,600
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID FLN001
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 36194FL0160003-00
Plan Marketing Name Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access)
Plan Type HMO
Plan Variant Marketing Name Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,900
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $1,600
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,000
SBC Scenario, Having Diabetes, Deductible $100
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $200
SBC Scenario, Treatment of a Simple Fracture, Copayment $100
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,600
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID FLS003
Source Name HIOS
Plan ID 36194FL0160003
State Code FL
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access) Health Insurance Plan, 36194FL0160003

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access), 36194FL0160003 Health Insurance Plan, 36194FL0160003

  • Does Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access) Health Insurance Plan, 36194FL0160003 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (36194FL0160003) Health Insurance Plan, Variant (36194FL0160003-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does (36194FL0160003) Health Insurance Plan, Variant (36194FL0160003-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (36194FL0160003) Health Insurance Plan, Variant (36194FL0160003-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

    Does (36194FL0160003) Health Insurance Plan, Variant (36194FL0160003-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access) Health Insurance Plan, Variant (36194FL0160003-00) offer Disease Management Programs for Heart disease?

    Yes, the Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access) Health Insurance Plan Variant 36194FL0160003-00 offers Disease Management Program for Heart disease.

    Does Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access) Health Insurance Plan, Variant (36194FL0160003-00) offer Disease Management Programs for Diabetes?

    Yes, the Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access) Health Insurance Plan Variant 36194FL0160003-00 offers Disease Management Program for Diabetes.

    Does Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access) Health Insurance Plan, Variant (36194FL0160003-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access) Health Insurance Plan Variant 36194FL0160003-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access) Health Insurance Plan, Variant (36194FL0160003-00) offer Disease Management Programs for Pregnancy?

    Yes, the Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, $0 Preventive Care, $2 Tier 1 Prescriptions, Open Access) Health Insurance Plan Variant 36194FL0160003-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API