Prestige Gold 50 + Dental + Vision - 81413WI0460016 Health Insurance Plan

Network Health Plan health insurance plan with the Plan ID 81413WI0460016. The plan is called Prestige Gold 50 + Dental + Vision.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.69% (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 21.31% 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 81413WI0460016
Health Insurance Plan Year 2022
State Wisconsin
Health Insurance Issuer Network Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 81413WI0460016-00
Provider Network(s) ['WIN001']
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 Wisconsin 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 - 81413WI0460016-00

Standard On Exchange Plan - 81413WI0460016-01

Open to Indians below 300% FPL - 81413WI0460016-02

Open to Indians above 300% FPL - 81413WI0460016-03

Last Plan Update Date Fri, 28 Jan 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Prestige Gold 50 + Dental + Vision Health Insurance Plan Variant 81413WI0460016-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.786898241
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
Dental Only Plan No
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 0.9886
First Tier Utilization 100%
Formulary ID WIF001
Formulary URL URL
HIOS Product ID 81413WI046
Import Date 1/28/2022 1:00
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 81413
Issuer Marketplace Marketing Name Network 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 WIN001
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Services or Urgent Care Services When services are performed in a free standing urgent care facility or hospital based urgent care
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Services or Urgent Care Services When services are performed in a free standing urgent care facility or hospital based urgent care
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 81413WI0460016-00
Plan Marketing Name Prestige Gold 50 + Dental + Vision
Plan Type HMO
Plan Variant Marketing Name Prestige Gold 50 + Dental + Vision
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,300
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $1,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,130
SBC Scenario, Having Diabetes, Deductible $910
SBC Scenario, Having Diabetes, Limit $60
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $900
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,000
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WIS001
Source Name HIOS
Plan ID 81413WI0460016
State Code WI
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 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $2000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $1000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,000
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 $8600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $4300 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $4,300
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 Prestige Gold 50 + Dental + Vision Health Insurance Plan, 81413WI0460016

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

Frequently Asked Questions(FAQ) about Prestige Gold 50 + Dental + Vision, 81413WI0460016 Health Insurance Plan, 81413WI0460016

  • Does Prestige Gold 50 + Dental + Vision Health Insurance Plan, 81413WI0460016 support Mail Ordering?

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

  • Does (81413WI0460016) Health Insurance Plan, Variant (81413WI0460016-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy, Weight Loss Programs

    Does (81413WI0460016) Health Insurance Plan, Variant (81413WI0460016-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services or Urgent Care Services When services are performed in a free standing urgent care facility or hospital based urgent care

    Does (81413WI0460016) Health Insurance Plan, Variant (81413WI0460016-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services or Urgent Care Services When services are performed in a free standing urgent care facility or hospital based urgent care

    Does (81413WI0460016) Health Insurance Plan, Variant (81413WI0460016-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy, Weight Loss Programs

    Does Prestige Gold 50 + Dental + Vision Health Insurance Plan, Variant (81413WI0460016-00) offer Disease Management Programs for Asthma?

    Yes, the Prestige Gold 50 + Dental + Vision Health Insurance Plan Variant 81413WI0460016-00 offers Disease Management Program for Asthma.

    Does Prestige Gold 50 + Dental + Vision Health Insurance Plan, Variant (81413WI0460016-00) offer Disease Management Programs for Heart disease?

    Yes, the Prestige Gold 50 + Dental + Vision Health Insurance Plan Variant 81413WI0460016-00 offers Disease Management Program for Heart disease.

    Does Prestige Gold 50 + Dental + Vision Health Insurance Plan, Variant (81413WI0460016-00) offer Disease Management Programs for Diabetes?

    Yes, the Prestige Gold 50 + Dental + Vision Health Insurance Plan Variant 81413WI0460016-00 offers Disease Management Program for Diabetes.

    Does Prestige Gold 50 + Dental + Vision Health Insurance Plan, Variant (81413WI0460016-00) offer Disease Management Programs for Pregnancy?

    Yes, the Prestige Gold 50 + Dental + Vision Health Insurance Plan Variant 81413WI0460016-00 offers Disease Management Program for Pregnancy.

    Does Prestige Gold 50 + Dental + Vision Health Insurance Plan, Variant (81413WI0460016-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Prestige Gold 50 + Dental + Vision Health Insurance Plan Variant 81413WI0460016-00 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