Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation) - 38345WI0240002 Health Insurance Plan

Dean Health Plan health insurance plan with the Plan ID 38345WI0240002. The plan is called Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.72% (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 28.28% 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 38345WI0240002
Health Insurance Plan Year 2023
State Wisconsin
Health Insurance Issuer Dean Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 38345WI0240002-00
Provider Network(s) ['WIN003']
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 - 38345WI0240002-00

Standard On Exchange Plan - 38345WI0240002-01

Open to Indians below 300% FPL - 38345WI0240002-02

Open to Indians above 300% FPL - 38345WI0240002-03

73% AV Silver Plan - 38345WI0240002-04

87% AV Silver Plan - 38345WI0240002-05

94% AV Silver Plan - 38345WI0240002-06

Last Plan Update Date Thu, 18 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation) Health Insurance Plan, 38345WI0240002-00

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

Exclusions: Surgery performed to correct functional deformities of the mandible or maxilla; correction of malocclusion; orthognathic surgery; orthodontic care, periodontic care or general dental care; tooth damage due to eating, chewing or biting.

These benefits are intended for dental treatment needed to remove, repair, replace, restore and/or reposition sound, natural teeth damaged, lost, or removed due to an injury. The term "injured" does not include conditions resulting from eating, chewing or biting. To be eligible for coverage, the services must be medically necessary while you are enrolled under this policy, dental services are received from a Doctor of Dental Surgery or Doctor of Medical Dentistry, and the tooth must meet the definition of "sound, natural tooth".

YES

30.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing

Exclusions: Cytotoxic testing and sublingual antigens associated to allergy testing.

YES

30.00% Coinsurance after deductible

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

Intravenous chemotherapy is covered.

YES

30.00% Coinsurance after deductible

100.00%
Chiropractic Care

Exclusions: Maintenance or long-term therapy; cervical pillows; spinal decompression devices.

YES

$40.00

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

Exclusions: Amniocentesis, CVS (Chorionic Villi Sampling), or non-invasive pre-natal testing when performed exclusively for sex determination; birthing classes; Services, drugs, or supplies related to abortions, except when: 1) a woman suffers from a physical disorder, physical injury, or physical illness that would place the woman in danger of death unless an abortion is performed, or 2) the pregnancy is the result of an act of rape or incest; home or intentional out-of-hospital deliveries; maternity services received outside the service area during the last 30 days of the pregnancy, except for emergency or urgent care services; Assisted Reproductive Technology (ART) services, treatment, supplies, and/or procedures for a non-member traditional surrogate or gestational carrier, who is not covered under this policy.

38345WI0240001-01 - [20.00% Coinsurance after deductible]; 38345WI0240001-02 - [0]; 38345WI0240001-03 - [20.00% Coinsurance after deductible]; 38345WI0240002-01 - [30.00% Coinsurance after deductible]; 38345WI0240002-02 - [0]; 38345WI0240002-03 - [30.00% Coinsurance after deductible]; 38345WI0240002-04 - [30.00% Coinsurance after deductible]; 38345WI0240002-05 - [10.00% Coinsurance after deductible]; 38345WI0240002-06 - [5.00% Coinsurance after deductible]; 38345WI0240003-01 - [No Charge after deductible]; 38345WI0240003-02 - [0]; 38345WI0240003-03 - [No Charge after deductible]; 38345WI0240005-01 - [No Charge after deductible]; 38345WI0240005-02 - [0]; 38345WI0240005-03 - [No Charge after deductible]; 38345WI0240006-01 - [30.00% Coinsurance after deductible]; 38345WI0240006-02 - [0]; 38345WI0240006-03 - [30.00% Coinsurance after deductible]; 38345WI0240006-04 - [20.00% Coinsurance after deductible]; 38345WI0240006-05 - [10.00% Coinsurance after deductible]; 38345WI0240006-06 - [5.00% Coinsurance after deductible]; 38345WI0240007-01 - [No Charge after deductible]; 38345WI0240007-02 - [0]; 38345WI0240007-03 - [No Charge after deductible]; 38345WI0240008-01 - [20.00% Coinsurance after deductible]; 38345WI0240008-02 - [0]; 38345WI0240008-03 - [20.00% Coinsurance after deductible]; 38345WI0240008-04 - [20.00% Coinsurance after deductible]; 38345WI0240008-05 - [5.00% Coinsurance after deductible]; 38345WI0240008-06 - [5.00% Coinsurance after deductible]; 38345WI0240009-01 - [No Charge after deductible]; 38345WI0240009-02 - [0]; 38345WI0240009-03 - [No Charge after deductible]; 38345WI0240010-01 - [No Charge after deductible]; 38345WI0240011-01 - [20.00% Coinsurance after deductible]; 38345WI0240011-02 - [0]; 38345WI0240011-03 - [20.00% Coinsurance after deductible]; 38345WI0240012-01 - [20.00% Coinsurance after deductible]; 38345WI0240012-02 - [0]; 38345WI0240012-03 - [20.00% Coinsurance after deductible]; 38345WI0240013-01 - [20.00% Coinsurance after deductible]; 38345WI0240013-02 - [0]; 38345WI0240013-03 - [20.00% Coinsurance after deductible]; 38345WI0240013-04 - [20.00% Coinsurance after deductible]; 38345WI0240013-05 - [20.00% Coinsurance after deductible]; 38345WI0240013-06 - [20.00% Coinsurance after deductible]; 38345WI0240014-01 - [20.00% Coinsurance after deductible]; 38345WI0240014-02 - [0]; 38345WI0240014-03 - [20.00% Coinsurance after deductible]

YES

30.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Exclusions: Educational services, except for diabetic education and diabetic self-management training classes.

Diabetic education; diabetic self-management training classes.

YES 100.00%
Dialysis
YES

30.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Exclusions: Medical supplies and durable medical equipment for comfort, personal hygiene and convenience, regardless of medical necessity of such items; Home testing and monitoring supplies and related equipment, except as covered by our medical policy; Equipment, models or devices that have features over and above what is Medically Necessary (Coverage will be limited to the standard model as determined by Us); Non-prescription elastic support or anti-embolism stockings; Shoes or foot orthotics not custom-made and purchased over the counter; Any durable medical equipment or supplies used for work, athletic, or job enhancement purposes; Cranial bands; Back-up equipment (a second piece); Replacement of durable medical equipment more frequently than every three years, unless defined by our medical policy or mandated by law; Replacement of an item that is lost, stolen, or unusable/nonfunctioning because of misuse, abuse, or neglect; Items that can be purchased over the counter, unless coverage is required by state or federal law; Oral Nutrition: Oral nutrition is not considered a medical item. We do not cover nutritional support that is taken orally (i.e., by mouth), unless mandated by law or covered under our medical policy for a specific condition; Technology devices that are not primarily and customarily used to serve a medical purpose such as desktop computers, portable multi-media players, smart phones, tablet devices and similar items are not considered durable medical equipment.

Covers medical supplies and durable medical equipment. Examples include, but are not limited to: wheelchairs, tube feeding nutrition supplies; hospital beds; oxygen and respiratory equipment; walking aids; orthopedic products; urological and ostomy supplies; orthotics and prosthetics; diabetic durable equipment and insulin infusion pumps (Insulin infusion pumps are limited to one pump per contract period and the member must use the pump for 30 days before purchasing.); other medical supplies as determined by us.

YES

30.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

$500.00 Copay with deductible, 30.00% Coinsurance after deductible

$500.00 Copay with deductible, 30.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Exclusions: Non-emergency or non-urgent ground or air ambulance services or transportation, unless the transportation or service is listed as a covered expense or prior authorized by us; Charges for, or in connection with, any other form of travel, unless otherwise stated in this section; Member's condition does not meet medical criteria for ambulance services or transportation; Any ambulance transportation or services initiated for convenience or non-medical reasons.

YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Exclusions: Blended segment lenses; intermediate vision lenses; standard progressives; premium progressives; photochromic glass lenses; plastic photosensitive lenses; polarized lenses; standard anti-reflective (AR) coating; premium AR coating.

One pair of prescription eyeglasses per year, as follows: glass or plastic lenses; single vision, conventional (lined) bifocal and conventional (lined) trifocal lenses; polycarbonate lenses (monocular or patients with prescriptions greater than a +6.00 or -6.00 diopter); frame; scratch resistant coating; ultraviolet protective coating. One replacement pair of eyeglasses per year. Contact lenses. Benefits for contact lenses are in lieu of your eyeglass lens benefit. If you receive contact lenses, no benefit will be available for eyeglasses until the next contract period.

YES

30.00% Coinsurance after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs
YES

$15.00

100.00%
Habilitation Services

Limit: 60.0 Visit(s) per Year

Exclusions: Custodial care; daycare; recreational care; respite care; vocational or life training.

Separate 20 visit(s) limit per therapy type per year for Physical, Occupational and Speech Therapy. Habilitative Services and devices are those services and devices that help a person keep, learn, or improve skills and functioning for daily living. Covered expenses include medically necessary physical therapy, occupational therapy and speech therapy, counseling, behavioral health services, and services for developmental delay.

YES

$40.00

100.00%
Hearing Aids

Limit: 2.0 Item(s) per 3 Years

Exclusions: Batteries and chargers for hearing aids. Hearing aids that can be bought without a prescription and the following: a fully implantable middle ear hearing aid; non-implantable, intraoral bone conduction hearing aid.

Limited to one hearing aid per ear or one set of bilateral hearing aids (both ears) and ear molds, including dispensing fees. Benefits are available per benefit period. The benefit period is 36 consecutive months from the date the benefit is first used; Repairs as medically necessary; The hearing aid must be repaired by/purchased from an authorized provider; Cochlear implants, for children and adults, including procedures for implantation and post-cochlear implant aural therapy; Bone-anchored hearing aids.

YES

30.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

Exclusions: Residential care; private duty nursing; home care services provided by a family member or someone who resides with the member; custodial care or any service that is not required to be provided by a skilled/licensed provider.

YES

30.00% Coinsurance after deductible

100.00%
Hospice Services

Exclusions: Residential care; services provided by volunteers; housekeeping or homemaking services.

YES

30.00% Coinsurance after deductible

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

30.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy

Exclusions: A drug or biologic that is not considered medically necessary. Home infusion administered by a family member or someone who resides with a family member.

YES

30.00% Coinsurance after deductible

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

Exclusions: Take home drugs and supplies dispensed by the hospital, unless a written prescription is obtained and filled at a network pharmacy; hospital stays that are extended for reasons other than medical necessity; a continued hospital stay, if the attending health care provider has documented that care could effectively be provided in a less acute care setting; separate charges for personal comfort or convenience items.

YES

30.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

30.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

30.00% Coinsurance 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
YES

30.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

Exclusions: Biofeedback; family counseling for non-medical reasons; wilderness and camp programs, boarding school, academy-vocational programs and group homes; halfway houses; hypnotherapy; long-term or maintenance therapy; marriage counseling; phototherapy.

YES

$40.00

100.00%
Non-Preferred Brand Drugs
YES

50.00%

100.00%
Nutritional Counseling

A registered or certified dietitian must give or supervise these services.

YES

30.00% Coinsurance after deductible

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

$40.00

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

30.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Year

Exclusions: Vocational rehabilitation, including work hardening programs; hearing therapy for communication delay, therapy for perceptual disorders, intellectual disability and related conditions, and other long-term special therapy, except as specifically listed under habilitative services or autism spectrum disorder section; therapy services such as recreational or educational therapy, physical fitness or exercise programs; services to enhance athletic training or performance; services or treatment received at intermediate care facilities; submaximal stress testing except for members with cardiovascular disease.

Separate 20 visit(s) limit per therapy type per year for Physical, Occupational and Speech Therapy. Pulmonary rehab has no visit limits. Cardiac Rehabilitation has no visit limits. These therapy benefits are only for treatment of those conditions that, in the judgment of the attending health care provider, are expected to yield significant patient improvement, as determined by us. Therapists must be licensed and must not live in the patient's home or be a family member.

YES

$40.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

30.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$60.00

100.00%
Prenatal and Postnatal Care

Exclusions: Amniocentesis, CVS (Chorionic Villi Sampling), or non-invasive pre-natal testing when performed exclusively for sex determination; birthing classes; Services, drugs, or supplies related to abortions, except when: 1) a woman suffers from a physical disorder, physical injury, or physical illness that would place the woman in danger of death unless an abortion is performed, or 2) the pregnancy is the result of an act of rape or incest; home or intentional out-of-hospital deliveries; maternity services received outside the service area during the last 30 days of the pregnancy, except for emergency or urgent care services; Assisted Reproductive Technology (ART) services, treatment, supplies, and/or procedures for a non-member traditional surrogate or gestational carrier, who is not covered under this policy.

YES

30.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES 100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$40.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices

Exclusions: Medical supplies and durable medical equipment for comfort, personal hygiene and convenience, regardless of medical necessity of such items; Home testing and monitoring supplies and related equipment, except as covered by our medical policy; Equipment, models or devices that have features over and above what is medically necessary (Coverage will be limited to the standard model as determined by us); Non-prescription elastic support or anti-embolism stockings; Shoes or foot orthotics not custom-made and purchased over the counter; Any durable medical equipment or supplies used for work, athletic, or job enhancement purposes; Cranial bands; Back-up equipment (a second piece); Replacement of durable medical equipment more frequently than every three years, unless defined by our medical policy or mandated by law; Replacement of an item that is lost, stolen, or unusable/nonfunctioning because of misuse, abuse, or neglect; Items that can be purchased over the counter, unless coverage is required by state or federal law.

YES

30.00% Coinsurance after deductible

100.00%
Radiation
YES

30.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Exclusions: Non-medically necessary plastic surgery. This limitation does not affect coverage provided for breast reconstruction in connection with a mastectomy.

YES

30.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Year

Exclusions: Vocational rehabilitation, including work hardening programs; hearing therapy for communication delay, therapy for perceptual disorders, intellectual disability and related conditions, and other long-term special therapy, except as specifically listed under habilitative services or autism spectrum disorder section; therapy services such as recreational or educational therapy, physical fitness or exercise programs; services to enhance athletic training or performance; services or treatment received at intermediate care facilities; submaximal stress testing except for members with cardiovascular disease.

Separate 20 visit(s) limit per therapy type per year for physical and occupational therapy. These therapy benefits are only for treatment of those conditions that, in the judgment of the attending health care provider, are expected to yield significant patient improvement, as determined by us. Therapists must be licensed and must not live in the patient's home or be a family member.

YES

$40.00

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Exclusions: Vocational rehabilitation, including work hardening programs; hearing therapy for communication delay, therapy for perceptual disorders, intellectual disability and related conditions, and other long-term special therapy, except as specifically listed under habilitative services or autism spectrum disorder section; therapy services such as recreational or educational therapy, physical fitness or exercise programs; services to enhance athletic training or performance; services or treatment received at intermediate care facilities; submaximal stress testing except for members with cardiovascular disease.

20 visit(s) limit per year for Speech Therapy. These therapy benefits are only for treatment of those conditions that, in the judgment of the attending health care provider, are expected to yield significant patient improvement, as determined by us. Therapists must be licensed and must not live in the patient's home or be a family member.

YES

$40.00

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

Limit: 1.0 Exam(s) per Benefit Period

Exclusions: Refractive eye surgery and radial keratotomy; contact lenses (except as a part of cataract surgery or therapeutic contact lenses as defined by our medical policy); refractive exams related to contact lenses; any fitting of contact lenses (except for fitting of therapeutic contact lenses as defined by our medical policy); refraction aids for low vision and instruction in their use.

YES

$40.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Stay

Exclusions: Respite and residential care; any nursing facility services other than skilled nursing services, including intermediate care facilities and community re-entry programs; custodial care; charges for injectable medications administered in a nursing home when we do not cover the nursing home stay; tracheostomy care (if not skilled care); parenteral feeding or tube feeding care.

YES

30.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$80.00

100.00%
Specialty Drugs
YES

50.00%

100.00%
Substance Abuse Disorder Inpatient Services
YES

30.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Exclusions: Biofeedback; family counseling for non-medical reasons; wilderness and camp programs, boarding school, academy-vocational programs and group homes; halfway houses; hypnotherapy; long-term or maintenance therapy; marriage counseling; phototherapy.

YES

$40.00

100.00%
Transplant

Exclusions: Health services for organ and tissue transplants unless specifically covered under the policy. Organ procurement costs for a member who is donating an organ to another person. Health services for transplants involving permanent mechanical or animal organs. Transplant services that are not performed at an approved facility. Services and supplies in connection with covered transplants when prior authorization is not obtained. Any experimental or investigational transplant. Transplants involving non-human or artificial organs.

YES

30.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Diagnostic procedures and medically necessary surgical or non-surgical treatment for the correction of temporomandibular disorders (TMD), if the following apply: Services are provided under the accepted standards of the profession of the health care provider providing the service, the procedure or device is reasonable and appropriate for the diagnosis or treatment of this condition, the purpose of the procedure or device is to control or eliminate infection, pain, disease or dysfunction; Orthognathic surgery only for the treatment of TMD, when prior authorized by us.

YES

30.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$40.00

$40.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES 100.00%
X-rays and Diagnostic Imaging
YES

30.00% Coinsurance after deductible

100.00%

Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation) Health Insurance Plan Variant 38345WI0240002-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.717187619
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 Silver Off Exchange Plan
Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 30.00%
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
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Out of Network, Individual Not Applicable
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID WIF006
Formulary URL URL
HIOS Product ID 38345WI024
Import Date 8/18/2022 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 38345
Issuer Marketplace Marketing Name Dean Health Plan
Market Coverage Individual
Medical Drug Deductibles Integrated No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 30.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $9600 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $4800 per person
Medical EHB Deductible, In Network (Tier 1), Individual $4,800
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID WIN003
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Only
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 38345WI0240002-00
Plan Level Exclusions See policy or plan document for additional excluded services.
Plan Marketing Name Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation)
Plan Type HMO
Plan Variant Marketing Name Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,300
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $4,800
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 $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $800
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,700
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WIS005
Source Name HIOS
Plan ID 38345WI0240002
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
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 Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation) Health Insurance Plan, 38345WI0240002

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

Frequently Asked Questions(FAQ) about Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation), 38345WI0240002 Health Insurance Plan, 38345WI0240002

  • Does Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation) Health Insurance Plan, 38345WI0240002 support Mail Ordering?

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

  • Does (38345WI0240002) Health Insurance Plan, Variant (38345WI0240002-00) offer Disease Management Programs?

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

    Does (38345WI0240002) Health Insurance Plan, Variant (38345WI0240002-00) have Out Of Country Coverage?

    Yes. Details: Emergency Only

    Does (38345WI0240002) Health Insurance Plan, Variant (38345WI0240002-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Only

    Does (38345WI0240002) Health Insurance Plan, Variant (38345WI0240002-00) offer Disease Management Programs?

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

    Does Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation) Health Insurance Plan, Variant (38345WI0240002-00) offer Disease Management Programs for Asthma?

    Yes, the Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation) Health Insurance Plan Variant 38345WI0240002-00 offers Disease Management Program for Asthma.

    Does Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation) Health Insurance Plan, Variant (38345WI0240002-00) offer Disease Management Programs for Heart disease?

    Yes, the Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation) Health Insurance Plan Variant 38345WI0240002-00 offers Disease Management Program for Heart disease.

    Does Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation) Health Insurance Plan, Variant (38345WI0240002-00) offer Disease Management Programs for Diabetes?

    Yes, the Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation) Health Insurance Plan Variant 38345WI0240002-00 offers Disease Management Program for Diabetes.

    Does Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation) Health Insurance Plan, Variant (38345WI0240002-00) offer Disease Management Programs for Pregnancy?

    Yes, the Prevea360 Silver Copay Plus 4800X (Free Virtual Care & Transportation) Health Insurance Plan Variant 38345WI0240002-00 offers Disease Management Program for Pregnancy.

 

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