Utah Preferred Plan (Pediatric Only) - 87169UT0050004 Health Insurance Plan

Renaissance Life & Health Insurance Company of America health insurance plan with the Plan ID 87169UT0050004. The plan is called Utah Preferred Plan (Pediatric Only).

Health Insurance Plan ID 87169UT0050004
Health Insurance Plan Year 2023
State Utah
Health Insurance Issuer Renaissance Life & Health Insurance Company of America
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 87169UT0050004-00
Provider Network(s) ['UTN001']
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 Utah 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 - 87169UT0050004-00

Standard On Exchange Plan - 87169UT0050004-01

Last Plan Update Date Wed, 17 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Utah Preferred Plan (Pediatric Only) Health Insurance Plan, 87169UT0050004-00

Benefit Covered In Network Out Of Network
Accidental Dental
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Dental Check-Up for Children

Limit: 2.0 Procedure(s) per Benefit Period

Exclusions: See Plan Brochure.

Routine cleaning, exams, x-rays and fluoride. Sealants once every five years.

YES

0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Orthodontia - Adult
NO
Orthodontia - Child
NO
Routine Dental Services (Adult)
NO

Utah Preferred Plan (Pediatric Only) Health Insurance Plan Variant 87169UT0050004-00 Attributes

Plan Attribute Value
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 Child-Only
Composite Rating Offered No
CSR Variation Type Standard Low Off Exchange Plan
Dental Only Plan Yes
EHB Apportionment for Pediatric Dental 1
First Tier Utilization 100%
HIOS Product ID 87169UT005
Import Date 8/17/2022 20:01
Inpatient Copayment Maximum Days 0
Guaranteed Rate Guaranteed Rate
New/Existing Plan Existing
Issuer ID 87169
Issuer Marketplace Marketing Name Renaissance Dental
Market Coverage Individual
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Not Applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Group $150 per group
Medical EHB Deductible, Combined In/Out of Network, Family Per Person $50 per person
Medical EHB Deductible, Combined In/Out of Network, Individual $50
Medical EHB Deductible, In Network (Tier 1), Family Per Group per group not applicable
Medical EHB Deductible, In Network (Tier 1), Family Per Person per person not applicable
Medical EHB Deductible, In Network (Tier 1), Individual Not Applicable
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
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group $750 per group
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person $375 per person
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual $375
Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual Not Applicable
Metal Level Low
Multiple In Network Tiers No
National Network Yes
Network ID UTN001
Out of Country Coverage Yes
Out of Country Coverage Description Benefits paid at the Out of Network Level.
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Same Benefit Level
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 87169UT0050004-00
Plan Marketing Name Utah Preferred Plan (Pediatric Only)
Plan Type PPO
Plan Variant Marketing Name Utah Preferred Plan (Pediatric Only)
QHP/Non QHP Both
Service Area ID UTS001
Source Name SERFF
Plan ID 87169UT0050004
State Code UT
URL for Enrollment Payment URL

Copay & Coinsurance of Utah Preferred Plan (Pediatric Only) Health Insurance Plan, 87169UT0050004

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

Frequently Asked Questions(FAQ) about Utah Preferred Plan (Pediatric Only), 87169UT0050004 Health Insurance Plan, 87169UT0050004

  • Does Utah Preferred Plan (Pediatric Only) Health Insurance Plan, 87169UT0050004 support Mail Ordering?

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

  • Does (87169UT0050004) Health Insurance Plan, Variant (87169UT0050004-00) have Out Of Country Coverage?

    Yes. Details: Benefits paid at the Out of Network Level.

    Does (87169UT0050004) Health Insurance Plan, Variant (87169UT0050004-00) have Out of Service Area Coverage?

    Yes. Details: Same Benefit Level

 

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