| Field | Data |
|---|---|
| Health Insurance Plan ID | 29698MI0540598 |
| Health Insurance Plan Year | 2022 |
| State | Michigan |
| Health Insurance Issuer | Priority Health |
| Plan Formulary Description URL | Formulary URL |
| Plan Marketing Materials URL | Marketing URL |
| Last Plan Update Date | Wed, 22 Sep 2021 00:00 GMT |
| Last Import Date | Tue, 21 Mar 2023 13:10 GMT |
| Health Insurance Plan Variant | 29698MI0540598-03 |
| Available Variants of the Health Plan | |
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.81799485 |
| 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 | Limited Cost Sharing Plan Variation |
| 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 | MIF009 |
| Formulary URL | URL |
| HIOS Product ID | 29698MI054 |
| Import Date | 8/17/2021 20:00 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 5 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 29698 |
| Issuer Marketplace Marketing Name | Priority Health |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MIN005 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Care Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Urgent/Emergency Care Only |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 29698MI0540598-03 |
| Plan Marketing Name | MyPriority Gold Copay+ - Ascension St. John Providence Network |
| Plan Type | HMO |
| Plan Variant Marketing Name | MyPriority Gold Copay+ - Ascension St. John Providence Network |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $2,900 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $400 |
| SBC Scenario, Having Diabetes, Copayment | $1,500 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MIS005 |
| Source Name | SERFF |
| Plan ID | 29698MI0540598 |
| State Code | MI |
| 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 | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| TEHBDedOutOfNetFamilyPerGroup | per group not applicable |
| TEHBDedOutOfNetFamilyPerPerson | 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 | $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 |
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|---|---|---|---|---|---|
| Generic | 1 month in retail | $20.0 | After deductible | 0% | YES | |
| Generic preferred brand specialty drugs | 1 month in retail | $0 | 50.0% | After deductible | NO | |
| Medical service drugs | 1 month in retail | $0 | 0% | NO | ||
| Non preferred brand | 1 month in retail | $100.0 | After deductible | 0% | YES | |
| Non preferred brand specialty drugs | 1 month in retail | $0 | 50.0% | After deductible | NO | |
| Preferred brand | 1 month in retail | $75.0 | After deductible | 0% | YES | |
| Preferred generic | 1 month in retail | $5.0 | After deductible | 0% | YES |
Frequently Asked Questions(FAQ) about MyPriority Gold Copay+ - Ascension St. John Providence Network, 29698MI0540598 Health Insurance Plan, 29698MI0540598
Does MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan, 29698MI0540598 support Mail Ordering?
Yes, MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance
Plan, 29698MI0540598 supports mail ordering for the next drug tiers: Generic, Non preferred brand, Preferred brand, Preferred generic
What are the Generic Medications coinsurance & copay options with MyPriority Gold Copay+ - Ascension St. John Providence Network (29698MI0540598) Health Insurance Plan?
For generic drug tier copay (After deductible) is $20.0, generic preferred brand specialty drugs drug tier coinsurance (After deductible) is 50.0%, preferred generic drug tier copay (After deductible) is $5.0
What are the copay and coinsurance options for Brand Drugs with MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan (29698MI0540598)?
For generic preferred brand specialty drugs drug tier coinsurance (After deductible) is 50.0%, non preferred brand drug tier copay (After deductible) is $100.0, non preferred brand specialty drugs drug tier coinsurance (After deductible) is 50.0%, preferred brand drug tier copay (After deductible) is $75.0
What are the copay and coinsurance options for Brand Drugs with MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan (29698MI0540598)?
, generic preferred brand specialty drugs drug tier coinsurance (After deductible) is 50.0%, non preferred brand drug tier copay (After deductible) is $100.0, non preferred brand specialty drugs drug tier coinsurance (After deductible) is 50.0%, preferred brand drug tier copay (After deductible) is $75.0
Does (29698MI0540598) Health Insurance Plan, Variant (29698MI0540598-03) 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 (29698MI0540598) Health Insurance Plan, Variant (29698MI0540598-03) have Out Of Country Coverage?
Yes. Details: Emergency Care Only
Does (29698MI0540598) Health Insurance Plan, Variant (29698MI0540598-03) have Out of Service Area Coverage?
Yes. Details: Urgent/Emergency Care Only
Does (29698MI0540598) Health Insurance Plan, Variant (29698MI0540598-03) 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 MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan, Variant (29698MI0540598-03) offer Disease Management Programs for Asthma?
Yes, the MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan Variant 29698MI0540598-03 offers Disease Management Program for Asthma.
Does MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan, Variant (29698MI0540598-03) offer Disease Management Programs for Heart disease?
Yes, the MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan Variant 29698MI0540598-03 offers Disease Management Program for Heart disease.
Does MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan, Variant (29698MI0540598-03) offer Disease Management Programs for Depression?
Yes, the MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan Variant 29698MI0540598-03 offers Disease Management Program for Depression.
Does MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan, Variant (29698MI0540598-03) offer Disease Management Programs for Diabetes?
Yes, the MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan Variant 29698MI0540598-03 offers Disease Management Program for Diabetes.
Does MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan, Variant (29698MI0540598-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan Variant 29698MI0540598-03 offers Disease Management Program for High blood pressure & high cholesterol.
Does MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan, Variant (29698MI0540598-03) offer Disease Management Programs for Low back pain?
Yes, the MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan Variant 29698MI0540598-03 offers Disease Management Program for Low back pain.
Does MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan, Variant (29698MI0540598-03) offer Disease Management Programs for Pain management?
Yes, the MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan Variant 29698MI0540598-03 offers Disease Management Program for Pain management.
Does MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan, Variant (29698MI0540598-03) offer Disease Management Programs for Pregnancy?
Yes, the MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan Variant 29698MI0540598-03 offers Disease Management Program for Pregnancy.
Does MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan, Variant (29698MI0540598-03) offer Disease Management Programs for Weight loss programs?
Yes, the MyPriority Gold Copay+ - Ascension St. John Providence Network Health Insurance Plan Variant 29698MI0540598-03 offers Disease Management Program for Weight loss programs.
Disclaimer: This is based on the import(Date: Tue, 21 Mar 2023 13:10 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