Healthy Premier Bronze HSA - 42261UT0060003 Health Insurance Plan

University of Utah Health Insurance Plans health insurance plan with the Plan ID 42261UT0060003. The plan is called Healthy Premier Bronze HSA.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 63.33% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 36.67% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.06% (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 36.94% 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 42261UT0060003
Health Insurance Plan Year 2023
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 42261UT0060003-00
Provider Network(s) ['UTN001']
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 - 42261UT0060003-00

Standard On Exchange Plan - 42261UT0060003-01

Open to Indians below 300% FPL - 42261UT0060003-02

Open to Indians above 300% FPL - 42261UT0060003-03

Last Plan Update Date Wed, 17 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Healthy Premier Bronze HSA Health Insurance Plan, 42261UT0060003-00

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

Charges for office visits in connection with repetitive injections are not covered. Sublingual or colorimetric allergy testing.

YES

No Charge after deductible

100.00%
Autism Spectrum Disorders
YES

No Charge after deductible

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

No Charge after deductible

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

No Charge after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Must be for the diagnosis of diabetes.

YES

No Charge after deductible

100.00%
Dialysis
YES

No Charge after deductible

100.00%
Durable Medical Equipment

DME over $1000, rentals, that exceed 60 days, or as indicated in Appendix A of the Master Policy require Pre-authorization.

YES

No Charge after deductible

100.00%
Emergency Room Services
YES

No Charge after deductible

No Charge after deductible
Emergency Transportation/Ambulance
YES

No Charge after deductible

No Charge after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

Lenses only.

YES

0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Gender Affirming Care
YES

No Charge after deductible

100.00%
Generic Drugs

Limit: 30.0 Item(s) per Month

YES

No Charge after deductible

100.00%
Habilitation Services

Limit: 20.0 Visit(s) per Benefit Period

Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year

YES

No Charge after deductible

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 30.0 Visit(s) per Benefit Period

YES

No Charge after deductible

100.00%
Hospice Services

Limit: 6.0 Months per 3 Years

Requires Pre-authorization and Medical Case Management.

YES

No Charge after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

No Charge after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

No Charge after deductible

100.00%
Inherited Metabolic Disorder - PKU
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Inpatient Physician and Surgical Services
YES

No Charge after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

No Charge after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

Requires Pre-authorization.

YES

No Charge after deductible

100.00%
Mental/Behavioral Health Outpatient Services

Office Visits will be subject to a Copay, All other outpatient services are subject to the deductible and coinsurance

YES

No Charge after deductible

100.00%
Non-Preferred Brand Drugs

Limit: 30.0 Item(s) per Month

YES

No Charge after deductible

100.00%
Nutritional Counseling
NO
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Benefit Period

Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year

YES

No Charge after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

No Charge after deductible

100.00%
Preferred Brand Drugs

Limit: 30.0 Item(s) per Month

YES

No Charge after deductible

100.00%
Prenatal and Postnatal Care
YES

No Charge after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

No Charge after deductible

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
NO
Radiation
YES

No Charge after deductible

100.00%
Reconstructive Surgery

Covers mastectomy in the treatment of cancer and reconstructive surgery after a mastectomy.

YES

No Charge after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Benefit Period

Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year

YES

No Charge after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Benefit Period

Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year

YES

No Charge after deductible

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

Limit: 1.0 Visit(s) per Benefit Period

YES

0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Visit(s) per Benefit Period

Requires Pre-authorization and Medical Case Management.

YES

No Charge after deductible

100.00%
Specialist Visit
YES

No Charge after deductible

100.00%
Specialty Drugs

Limit: 30.0 Item(s) per Month

YES

No Charge after deductible

100.00%
Substance Abuse Disorder Inpatient Services

Requires Pre-authorization.

YES

No Charge after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Office Visits will be subject to a Copay, All other outpatient services are subject to the deductible and coinsurance

YES

No Charge after deductible

100.00%
Transplant
YES

No Charge after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

No Charge after deductible

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care

Benefit should mirror preventive care/screening/immunization.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

No Charge after deductible

100.00%

Healthy Premier Bronze HSA Health Insurance Plan Variant 42261UT0060003-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.630602565
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 Bronze Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
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 UTF005
Formulary URL URL
HIOS Product ID 42261UT006
Import Date 8/17/2022 20:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 63.33%
Issuer ID 42261
Issuer Marketplace Marketing Name University of Utah Health Plans
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Expanded Bronze
Multiple In Network Tiers No
National Network No
Network ID UTN001
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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 42261UT0060003-00
Plan Level Exclusions See Plan Document
Plan Marketing Name Healthy Premier Bronze HSA
Plan Type EPO
Plan Variant Marketing Name Healthy Premier Bronze HSA
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $7,500
SBC Scenario, Having a Baby, Limit $50
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $5,300
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID UTS002
Source Name SERFF
Plan ID 42261UT0060003
State Code UT
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
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $15000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,500
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Individual Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $15000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,500
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 Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of Healthy Premier Bronze HSA Health Insurance Plan, 42261UT0060003

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

Frequently Asked Questions(FAQ) about Healthy Premier Bronze HSA, 42261UT0060003 Health Insurance Plan, 42261UT0060003

  • Does Healthy Premier Bronze HSA Health Insurance Plan, 42261UT0060003 support Mail Ordering?

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

  • Does (42261UT0060003) Health Insurance Plan, Variant (42261UT0060003-00) 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 (42261UT0060003) Health Insurance Plan, Variant (42261UT0060003-00) 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 (42261UT0060003) Health Insurance Plan, Variant (42261UT0060003-00) 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 (42261UT0060003) Health Insurance Plan, Variant (42261UT0060003-00) 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 Premier Bronze HSA Health Insurance Plan, Variant (42261UT0060003-00) offer Disease Management Programs for Asthma?

    Yes, the Healthy Premier Bronze HSA Health Insurance Plan Variant 42261UT0060003-00 offers Disease Management Program for Asthma.

    Does Healthy Premier Bronze HSA Health Insurance Plan, Variant (42261UT0060003-00) offer Disease Management Programs for Heart disease?

    Yes, the Healthy Premier Bronze HSA Health Insurance Plan Variant 42261UT0060003-00 offers Disease Management Program for Heart disease.

    Does Healthy Premier Bronze HSA Health Insurance Plan, Variant (42261UT0060003-00) offer Disease Management Programs for Depression?

    Yes, the Healthy Premier Bronze HSA Health Insurance Plan Variant 42261UT0060003-00 offers Disease Management Program for Depression.

    Does Healthy Premier Bronze HSA Health Insurance Plan, Variant (42261UT0060003-00) offer Disease Management Programs for Diabetes?

    Yes, the Healthy Premier Bronze HSA Health Insurance Plan Variant 42261UT0060003-00 offers Disease Management Program for Diabetes.

    Does Healthy Premier Bronze HSA Health Insurance Plan, Variant (42261UT0060003-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Healthy Premier Bronze HSA Health Insurance Plan Variant 42261UT0060003-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Healthy Premier Bronze HSA Health Insurance Plan, Variant (42261UT0060003-00) offer Disease Management Programs for Low back pain?

    Yes, the Healthy Premier Bronze HSA Health Insurance Plan Variant 42261UT0060003-00 offers Disease Management Program for Low back pain.

    Does Healthy Premier Bronze HSA Health Insurance Plan, Variant (42261UT0060003-00) offer Disease Management Programs for Pregnancy?

    Yes, the Healthy Premier Bronze HSA Health Insurance Plan Variant 42261UT0060003-00 offers Disease Management Program for Pregnancy.

    Does Healthy Premier Bronze HSA Health Insurance Plan, Variant (42261UT0060003-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Healthy Premier Bronze HSA Health Insurance Plan Variant 42261UT0060003-00 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