Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits - 81413WI0470011 Health Insurance Plan

Network Health Plan health insurance plan with the Plan ID 81413WI0470011. The plan is called Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.96% (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 28.04% 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 81413WI0470011
Health Insurance Plan Year 2023
State Wisconsin
Health Insurance Issuer Network Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 81413WI0470011-00
Provider Network(s) ['WIN002']
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 - 81413WI0470011-00

Standard On Exchange Plan - 81413WI0470011-01

Open to Indians below 300% FPL - 81413WI0470011-02

Open to Indians above 300% FPL - 81413WI0470011-03

73% AV Silver Plan - 81413WI0470011-04

87% AV Silver Plan - 81413WI0470011-05

94% AV Silver Plan - 81413WI0470011-06

Last Plan Update Date Fri, 02 Dec 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan, 81413WI0470011-00

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

40.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

40.00% Coinsurance after deductible

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

Intravenous chemotherapy is covered.

YES

40.00% Coinsurance after deductible

100.00%
Chiropractic Care

Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy.

YES

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

One exam, cleaning, and X-ray per year

YES

No Charge

100.00%
Diabetes Education
YES

No Charge

100.00%
Dialysis
YES

40.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Will cover 20 DME devices/items per year, whether rented or purchased in accordance with the requirements set out in the Policy.

YES

40.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

$500.00 Copay after deductible

$500.00 Copay after deductible
Emergency Transportation/Ambulance
YES

$300.00

$300.00
Eye Glasses for Children

1 item per year

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs

Adherence Generics are available at $0 copay or 0% coinsurance after deductible for certain categories of medications.

YES

$20.00

100.00%
Habilitation Services

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. Limited to 20 visits per benefit year for each: Occupational, Speech, and Physical therapy.

YES

40.00% Coinsurance after deductible

100.00%
Hearing Aids

Covers the cost of basic hearing aids limited to one hearing aid per ear, including repair or replacement, once every three years.

YES

40.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less.

YES

40.00% Coinsurance after deductible

100.00%
Hospice Services
YES

No Charge

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

40.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services

A lower copay/coinsurance applies to certain labs for condition management of chronic diseases.

YES

$30.00

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

40.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$25.00

100.00%
Non-Preferred Brand Drugs
YES

50.00% Coinsurance after deductible

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

$25.00

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

40.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Rehabilitative services must be short term. Limited to 20 visits per benefit year for each: Occupational, Speech, Physical and Pulmonary therapy. Cardiac Rehabilitation Therapy is limited to 36 visits per benefit year.

YES

40.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$80.00

100.00%
Prenatal and Postnatal Care
YES

40.00% Coinsurance after deductible

100.00%
Prescription Drugs Other

Formulary Tier 5: Non-preferred specialty drugs

YES

50.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

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

$25.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices

Covers up to 10 prosthetic devices that replace a limb or a body part each Benefit Year.

YES

40.00% Coinsurance after deductible

100.00%
Radiation
YES

40.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

40.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Year

Limited to 20 visits per benefit year for each: Occupational and Physical therapy.

YES

40.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Rehabilitative services must be short term. Limited to 20 visits per benefit year for each: Speech therapy.

YES

40.00% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)

One exam, cleaning, and X-ray per year

YES

No Charge

100.00%
Routine Eye Exam (Adult)

1 Exam per year

YES

No Charge

100.00%
Routine Eye Exam for Children

1 Exam per year

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Stay

YES

40.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$80.00

100.00%
Specialty Drugs

The coinsurance for Non-preferred specialty drugs is 10% higher than Preferred Specialty drugs. There is No Cost for covered Specialty Drugs for the Native American/Alaskan Limited and Zero Cost share plans.

YES

40.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

40.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$25.00

100.00%
Transplant
YES

40.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Coverage for diagnostic procedures and non-surgical treatment limited to 10 services and/or devices per Benefit Year.

YES

40.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities

Urgent Care Outside the Service Area is only covered when furnished by an Emergency room or Hospital-based Urgent Care Facility.

YES

$80.00

$80.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

$60.00

100.00%

Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan Variant 81413WI0470011-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.719573363
Begin Primary Care Cost-Sharing After Number Of Visits 3
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 Silver Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 0.99443
First Tier Utilization 100%
Formulary ID WIF001
Formulary URL URL
HIOS Product ID 81413WI047
Import Date 12/2/2022 1:01
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 Silver
Multiple In Network Tiers No
National Network No
Network ID WIN002
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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 81413WI0470011-00
Plan Marketing Name Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits
Plan Type HMO
Plan Variant Marketing Name Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,590
SBC Scenario, Having a Baby, Copayment $250
SBC Scenario, Having a Baby, Deductible $4,600
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,920
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $60
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $690
SBC Scenario, Treatment of a Simple Fracture, Deductible $620
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WIS002
Source Name HIOS
Plan ID 81413WI0470011
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 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $9200 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $4600 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $4,600
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 $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,100
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 Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan, 81413WI0470011

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

Frequently Asked Questions(FAQ) about Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits, 81413WI0470011 Health Insurance Plan, 81413WI0470011

  • Does Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan, 81413WI0470011 support Mail Ordering?

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

  • Does (81413WI0470011) Health Insurance Plan, Variant (81413WI0470011-00) offer Disease Management Programs?

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

    Does (81413WI0470011) Health Insurance Plan, Variant (81413WI0470011-00) 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 (81413WI0470011) Health Insurance Plan, Variant (81413WI0470011-00) 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 (81413WI0470011) Health Insurance Plan, Variant (81413WI0470011-00) offer Disease Management Programs?

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

    Does Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan, Variant (81413WI0470011-00) offer Disease Management Programs for Asthma?

    Yes, the Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan Variant 81413WI0470011-00 offers Disease Management Program for Asthma.

    Does Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan, Variant (81413WI0470011-00) offer Disease Management Programs for Heart disease?

    Yes, the Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan Variant 81413WI0470011-00 offers Disease Management Program for Heart disease.

    Does Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan, Variant (81413WI0470011-00) offer Disease Management Programs for Diabetes?

    Yes, the Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan Variant 81413WI0470011-00 offers Disease Management Program for Diabetes.

    Does Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan, Variant (81413WI0470011-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan Variant 81413WI0470011-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan, Variant (81413WI0470011-00) offer Disease Management Programs for Pregnancy?

    Yes, the Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan Variant 81413WI0470011-00 offers Disease Management Program for Pregnancy.

    Does Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan, Variant (81413WI0470011-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Prestige Silver Essential + Dental + Vision + Fitness + 3 Free PCP Visits Health Insurance Plan Variant 81413WI0470011-00 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