| Field | Data |
|---|---|
| Health Insurance Plan ID | 37833WI0620088 |
| Health Insurance Plan Year | 2023 |
| State | Wisconsin |
| Health Insurance Issuer | Quartz Health Benefit Plans Corporation |
| Plan Formulary Description URL | Formulary URL |
| Plan Marketing Materials URL | Marketing URL |
| Last Plan Update Date | Fri, 28 Apr 2023 00:00 GMT |
| Last Import Date | Sun, 01 Oct 2023 10:53 GMT |
| Health Insurance Plan Variant | 37833WI0620088-00 |
| Available Variants of the Health Plan | |
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.81272748 |
| 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 Gold 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 | 0.00% |
| 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, In Network (Tier 2), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 2), Individual | $0 |
| DEHBDedOutOfNetFamilyPerGroup | per group not applicable |
| DEHBDedOutOfNetFamilyPerPerson | 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, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 0.9885 |
| First Tier Utilization | 80% |
| Formulary ID | WIF001 |
| Formulary URL | URL |
| HIOS Product ID | 37833WI062 |
| Import Date | 4/28/2023 4:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 81.62% |
| Issuer ID | 37833 |
| Issuer Marketplace Marketing Name | Quartz |
| 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 | 40.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $3600 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $1800 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,800 |
| Medical EHB Deductible, In Network (Tier 2), Default Coinsurance | 40.00% |
| Medical EHB Deductible, In Network (Tier 2), Family Per Group | $7200 per group |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | $3600 per person |
| Medical EHB Deductible, In Network (Tier 2), Individual | $3,600 |
| 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 | Gold |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | WIN003 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Room, Limited Coverage for Out of Area Student with approved Prior Authorization |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 37833WI0620088-00 |
| Plan Marketing Name | Tiered Choice Plus Gold I409 with Vision |
| Plan Type | HMO |
| Plan Variant Marketing Name | TIERED CHOICE PLUS GOLD I409 VALUE TIER RX W/VISION DIRECT |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,600 |
| SBC Scenario, Having a Baby, Copayment | $200 |
| SBC Scenario, Having a Baby, Deductible | $1,800 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $800 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 20% |
| Service Area ID | WIS003 |
| Source Name | HIOS |
| Plan ID | 37833WI0620088 |
| 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 | $7200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $3600 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,600 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $14400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $7200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $7,200 |
| 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 | Yes |
| 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 |
|---|
Frequently Asked Questions(FAQ) about Tiered Choice Plus Gold I409 with Vision, 37833WI0620088 Health Insurance Plan, 37833WI0620088
Does Tiered Choice Plus Gold I409 with Vision Health Insurance Plan, 37833WI0620088 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (37833WI0620088) Health Insurance Plan, Variant (37833WI0620088-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Does (37833WI0620088) Health Insurance Plan, Variant (37833WI0620088-00) have Out Of Country Coverage?
No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).
Does (37833WI0620088) Health Insurance Plan, Variant (37833WI0620088-00) have Out of Service Area Coverage?
Yes. Details: Emergency Room, Limited Coverage for Out of Area Student with approved Prior Authorization
Does (37833WI0620088) Health Insurance Plan, Variant (37833WI0620088-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Does TIERED CHOICE PLUS GOLD I409 VALUE TIER RX W/VISION DIRECT Health Insurance Plan, Variant (37833WI0620088-00) offer Disease Management Programs for Asthma?
Yes, the TIERED CHOICE PLUS GOLD I409 VALUE TIER RX W/VISION DIRECT Health Insurance Plan Variant 37833WI0620088-00 offers Disease Management Program for Asthma.
Does TIERED CHOICE PLUS GOLD I409 VALUE TIER RX W/VISION DIRECT Health Insurance Plan, Variant (37833WI0620088-00) offer Disease Management Programs for Heart disease?
Yes, the TIERED CHOICE PLUS GOLD I409 VALUE TIER RX W/VISION DIRECT Health Insurance Plan Variant 37833WI0620088-00 offers Disease Management Program for Heart disease.
Does TIERED CHOICE PLUS GOLD I409 VALUE TIER RX W/VISION DIRECT Health Insurance Plan, Variant (37833WI0620088-00) offer Disease Management Programs for Depression?
Yes, the TIERED CHOICE PLUS GOLD I409 VALUE TIER RX W/VISION DIRECT Health Insurance Plan Variant 37833WI0620088-00 offers Disease Management Program for Depression.
Does TIERED CHOICE PLUS GOLD I409 VALUE TIER RX W/VISION DIRECT Health Insurance Plan, Variant (37833WI0620088-00) offer Disease Management Programs for Diabetes?
Yes, the TIERED CHOICE PLUS GOLD I409 VALUE TIER RX W/VISION DIRECT Health Insurance Plan Variant 37833WI0620088-00 offers Disease Management Program for Diabetes.
Does TIERED CHOICE PLUS GOLD I409 VALUE TIER RX W/VISION DIRECT Health Insurance Plan, Variant (37833WI0620088-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the TIERED CHOICE PLUS GOLD I409 VALUE TIER RX W/VISION DIRECT Health Insurance Plan Variant 37833WI0620088-00 offers Disease Management Program for High blood pressure & high cholesterol.
Does TIERED CHOICE PLUS GOLD I409 VALUE TIER RX W/VISION DIRECT Health Insurance Plan, Variant (37833WI0620088-00) offer Disease Management Programs for Pregnancy?
Yes, the TIERED CHOICE PLUS GOLD I409 VALUE TIER RX W/VISION DIRECT Health Insurance Plan Variant 37833WI0620088-00 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