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Prevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation) - 38345WI0240001 Health Insurance Plan

Dean Health Plan health insurance plan with the Plan ID 38345WI0240001. The plan is called Prevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.80% (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 18.20% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Field Data
Health Insurance Plan ID38345WI0240001
Health Insurance Plan Year2023
StateWisconsin
Health Insurance IssuerDean Health Plan
Plan Formulary Description URLFormulary URL
Plan Marketing Materials URLMarketing URL
Last Plan Update DateThu, 18 Aug 2022 00:00 GMT
Last Import DateSun, 01 Oct 2023 10:53 GMT
Health Insurance Plan Variant38345WI0240001-00
 
Available Variants of the Health Plan

38345WI0240001-00

38345WI0240001-01

38345WI0240001-02

38345WI0240001-03

Prevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation) Health Insurance Plan Variant 38345WI0240001-00 Attributes

Plan Attribute Value
AV Calculator Output Number0.818005844
Begin Primary Care Cost-Sharing After Number Of Visits0
Begin Primary Care Deductible Coinsurance After Number Of Copays0
Business Year2023
Child-Only OfferingAllows Adult and Child-Only
Composite Rating OfferedNo
CSR Variation TypeStandard Gold Off Exchange Plan
Drug EHB Deductible, Combined In/Out of Network, Family Per Groupper group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Personper person not applicable
Drug EHB Deductible, Combined In/Out of Network, IndividualNot Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance20.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group$0 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person$0 per person
Drug EHB Deductible, In Network (Tier 1), Individual$0
DEHBDedOutOfNetFamilyPerGroupper group not applicable
DEHBDedOutOfNetFamilyPerPersonper person not applicable
Drug EHB Deductible, Out of Network, IndividualNot Applicable
Dental Only PlanNo
Design TypeNot Applicable
Disease Management Programs OfferedAsthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization100%
Formulary IDWIF006
Formulary URLURL
HIOS Product ID38345WI024
Import Date8/18/2022 1:00
Limited Cost Sharing Plan Variation - Estimated Advanced Payment$0.00
Inpatient Copayment Maximum Days0
HSA EligibleNo
New/Existing PlanExisting
Notice Required for PregnancyNo
Is a Referral Required for Specialist?No
Issuer ID38345
Issuer Marketplace Marketing NameDean Health Plan
Market CoverageIndividual
Medical Drug Deductibles IntegratedNo
Medical Drug Maximum Out of Pocket IntegratedYes
Medical EHB Deductible, Combined In/Out of Network, Family Per Groupper group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Personper person not applicable
Medical EHB Deductible, Combined In/Out of Network, IndividualNot Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance20.00%
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 Groupper group not applicable
Medical EHB Deductible, Out of Network, Family Per Personper person not applicable
Medical EHB Deductible, Out of Network, IndividualNot Applicable
Metal LevelGold
Multiple In Network TiersNo
National NetworkNo
Network IDWIN003
Out of Country CoverageYes
Out of Country Coverage DescriptionEmergency Only
Out of Service Area CoverageYes
Out of Service Area Coverage DescriptionEmergency Only
Plan BrochureURL
Plan Effective Date1/1/2023
Plan Expiration Date12/31/2023
Plan ID (Standard Component ID with Variant) 38345WI0240001-00
Plan Level ExclusionsSee policy or plan document for additional excluded services.
Plan Marketing NamePrevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation)
Plan TypeHMO
Plan Variant Marketing NamePrevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation)
QHP/Non QHPBoth
SBC Scenario, Having a Baby, Coinsurance$2,200
SBC Scenario, Having a Baby, Copayment$10
SBC Scenario, Having a Baby, Deductible$1,500
SBC Scenario, Having a Baby, Limit$60
SBC Scenario, Having Diabetes, Coinsurance$0
SBC Scenario, Having Diabetes, Copayment$1,200
SBC Scenario, Having Diabetes, Deductible$900
SBC Scenario, Having Diabetes, Limit$20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance$50
SBC Scenario, Treatment of a Simple Fracture, Copayment$700
SBC Scenario, Treatment of a Simple Fracture, Deductible$1,500
SBC Scenario, Treatment of a Simple Fracture, Limit$0
Service Area IDWIS005
Source NameHIOS
Plan ID38345WI0240001
State CodeWI
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Groupper group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Personper person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, IndividualNot Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group$11400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person$5700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual$5,700
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Groupper group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Personper person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, IndividualNot Applicable
Unique Plan DesignNo
URL for Enrollment PaymentURL
URL for Summary of Benefits & CoverageURL
Wellness Program OfferedNo

Copay & Coinsurance of Prevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation) Health Insurance Plan, 38345WI0240001

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

Frequently Asked Questions(FAQ) about Prevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation), 38345WI0240001 Health Insurance Plan, 38345WI0240001

Does Prevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation) Health Insurance Plan, 38345WI0240001 support Mail Ordering?

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

Does (38345WI0240001) Health Insurance Plan, Variant (38345WI0240001-00) offer Disease Management Programs?

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

Does (38345WI0240001) Health Insurance Plan, Variant (38345WI0240001-00) have Out Of Country Coverage?

Yes. Details: Emergency Only

Does (38345WI0240001) Health Insurance Plan, Variant (38345WI0240001-00) have Out of Service Area Coverage?

Yes. Details: Emergency Only

Does (38345WI0240001) Health Insurance Plan, Variant (38345WI0240001-00) offer Disease Management Programs?

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

Does Prevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation) Health Insurance Plan, Variant (38345WI0240001-00) offer Disease Management Programs for Asthma?

Yes, the Prevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation) Health Insurance Plan Variant 38345WI0240001-00 offers Disease Management Program for Asthma.

Does Prevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation) Health Insurance Plan, Variant (38345WI0240001-00) offer Disease Management Programs for Heart disease?

Yes, the Prevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation) Health Insurance Plan Variant 38345WI0240001-00 offers Disease Management Program for Heart disease.

Does Prevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation) Health Insurance Plan, Variant (38345WI0240001-00) offer Disease Management Programs for Diabetes?

Yes, the Prevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation) Health Insurance Plan Variant 38345WI0240001-00 offers Disease Management Program for Diabetes.

Does Prevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation) Health Insurance Plan, Variant (38345WI0240001-00) offer Disease Management Programs for Pregnancy?

Yes, the Prevea360 Gold Copay Plus 1500X (Free Virtual Care & Transportation) Health Insurance Plan Variant 38345WI0240001-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Sun, 01 Oct 2023 10:53 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