Healthy Preferred Gold Copay - 42261UT0060004 Health Insurance Plan

University of Utah Health Insurance Plans health insurance plan with the Plan ID 42261UT0060004. The plan is called Healthy Preferred Gold Copay.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.75% (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 20.25% 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 42261UT0060004
Health Insurance Plan Year 2022
State Utah
Health Insurance Issuer University of Utah Health Insurance Plans
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 42261UT0060004-00
Provider Network(s) ['UTN002']
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 Utah 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 - 42261UT0060004-00

Standard On Exchange Plan - 42261UT0060004-01

Open to Indians below 300% FPL - 42261UT0060004-02

Open to Indians above 300% FPL - 42261UT0060004-03

Last Plan Update Date Wed, 18 Aug 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Healthy Preferred Gold Copay Health Insurance Plan Variant 42261UT0060004-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.797527866
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2022
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 $1000 per group
Drug EHB Deductible, Combined In/Out of Network, Family Per Person $500 per person
Drug EHB Deductible, Combined In/Out of Network, Individual $500
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 20.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $1000 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $500 per person
Drug EHB Deductible, In Network (Tier 1), Individual $500
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
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID UTF001
Formulary URL URL
HIOS Product ID 42261UT006
Import Date 8/18/2021 20:00
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 42261
Issuer Marketplace Marketing Name University of Utah Health Plans
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 $3000 per group
Medical EHB Deductible, Combined In/Out of Network, Family Per Person $1500 per person
Medical EHB Deductible, Combined In/Out of Network, Individual $1,500
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 20.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $3000 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $1500 per person
Medical EHB Deductible, In Network (Tier 1), Individual $1,500
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 UTN002
Out of Country Coverage No
Out of Country Coverage Description Emergent Only
Out of Service Area Coverage No
Out of Service Area Coverage Description Emergent Only
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 42261UT0060004-00
Plan Level Exclusions See Plan Document
Plan Marketing Name Healthy Preferred Gold Copay
Plan Type EPO
Plan Variant Marketing Name Healthy Preferred Gold Copay
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,200
SBC Scenario, Having a Baby, Copayment $30
SBC Scenario, Having a Baby, Deductible $1,500
SBC Scenario, Having a Baby, Limit $50
SBC Scenario, Having Diabetes, Coinsurance $1,500
SBC Scenario, Having Diabetes, Copayment $400
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $100
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID UTS002
Source Name SERFF
Plan ID 42261UT0060004
State Code UT
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $14000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $7000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $7,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $14000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,000
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 Yes

Copay & Coinsurance of Healthy Preferred Gold Copay Health Insurance Plan, 42261UT0060004

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

Frequently Asked Questions(FAQ) about Healthy Preferred Gold Copay, 42261UT0060004 Health Insurance Plan, 42261UT0060004

  • Does Healthy Preferred Gold Copay Health Insurance Plan, 42261UT0060004 support Mail Ordering?

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

  • Does (42261UT0060004) Health Insurance Plan, Variant (42261UT0060004-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does (42261UT0060004) Health Insurance Plan, Variant (42261UT0060004-00) have Out Of Country Coverage?

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

    Does (42261UT0060004) Health Insurance Plan, Variant (42261UT0060004-00) have Out of Service Area Coverage?

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

    Does (42261UT0060004) Health Insurance Plan, Variant (42261UT0060004-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does Healthy Preferred Gold Copay Health Insurance Plan, Variant (42261UT0060004-00) offer Disease Management Programs for Asthma?

    Yes, the Healthy Preferred Gold Copay Health Insurance Plan Variant 42261UT0060004-00 offers Disease Management Program for Asthma.

    Does Healthy Preferred Gold Copay Health Insurance Plan, Variant (42261UT0060004-00) offer Disease Management Programs for Heart disease?

    Yes, the Healthy Preferred Gold Copay Health Insurance Plan Variant 42261UT0060004-00 offers Disease Management Program for Heart disease.

    Does Healthy Preferred Gold Copay Health Insurance Plan, Variant (42261UT0060004-00) offer Disease Management Programs for Depression?

    Yes, the Healthy Preferred Gold Copay Health Insurance Plan Variant 42261UT0060004-00 offers Disease Management Program for Depression.

    Does Healthy Preferred Gold Copay Health Insurance Plan, Variant (42261UT0060004-00) offer Disease Management Programs for Diabetes?

    Yes, the Healthy Preferred Gold Copay Health Insurance Plan Variant 42261UT0060004-00 offers Disease Management Program for Diabetes.

    Does Healthy Preferred Gold Copay Health Insurance Plan, Variant (42261UT0060004-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Healthy Preferred Gold Copay Health Insurance Plan Variant 42261UT0060004-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Healthy Preferred Gold Copay Health Insurance Plan, Variant (42261UT0060004-00) offer Disease Management Programs for Low back pain?

    Yes, the Healthy Preferred Gold Copay Health Insurance Plan Variant 42261UT0060004-00 offers Disease Management Program for Low back pain.

    Does Healthy Preferred Gold Copay Health Insurance Plan, Variant (42261UT0060004-00) offer Disease Management Programs for Pregnancy?

    Yes, the Healthy Preferred Gold Copay Health Insurance Plan Variant 42261UT0060004-00 offers Disease Management Program for Pregnancy.

    Does Healthy Preferred Gold Copay Health Insurance Plan, Variant (42261UT0060004-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Healthy Preferred Gold Copay Health Insurance Plan Variant 42261UT0060004-00 offers Disease Management Program for Weight loss programs.

 

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