WellFirst Gold Copay Plus 1500X - 47840MO0010001 Health Insurance Plan
Medica Central Insurance Company health insurance plan with the Plan ID 47840MO0010001. The plan is called WellFirst Gold Copay Plus 1500X.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.95% (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 18.05% 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 | 47840MO0010001 | ||||||||||||||||||
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| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Missouri | ||||||||||||||||||
| Health Insurance Issuer | Medica Central Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 47840MO0010001-00 | ||||||||||||||||||
| Provider Network(s) | ['MON001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Apr 2024 06:19 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 47840MO0010001-00 Standard On Exchange Plan - 47840MO0010001-01 |
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| Last Plan Update Date | Sat, 17 Jul 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Apr 2024 06:19 GMT |
WellFirst Gold Copay Plus 1500X Health Insurance Plan Variant 47840MO0010001-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.819481673 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2022 |
| 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 | 20.00% |
| 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 |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | MOF001 |
| Formulary URL | URL |
| HIOS Product ID | 47840MO001 |
| Import Date | 7/17/2021 1:02 |
| 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 | 47840 |
| Issuer Marketplace Marketing Name | WellFirst Health |
| 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 | 20.00% |
| 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 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 | No |
| National Network | No |
| Network ID | MON001 |
| 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 | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 47840MO0010001-00 |
| Plan Level Exclusions | See policy or plan document for additional excluded services. |
| Plan Marketing Name | WellFirst Gold Copay Plus 1500X |
| Plan Type | EPO |
| Plan Variant Marketing Name | WellFirst Gold Copay Plus 1500X |
| QHP/Non QHP | Both |
| 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 | $1,000 |
| 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 | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MOS001 |
| Source Name | HIOS |
| Plan ID | 47840MO0010001 |
| State Code | MO |
| 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 | $10200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $5100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,100 |
| 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 WellFirst Gold Copay Plus 1500X Health Insurance Plan, 47840MO0010001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about WellFirst Gold Copay Plus 1500X, 47840MO0010001 Health Insurance Plan, 47840MO0010001
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Does WellFirst Gold Copay Plus 1500X Health Insurance Plan, 47840MO0010001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (47840MO0010001) Health Insurance Plan, Variant (47840MO0010001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy
Does (47840MO0010001) Health Insurance Plan, Variant (47840MO0010001-00) have Out Of Country Coverage?
Yes. Details: Emergency Only
Does (47840MO0010001) Health Insurance Plan, Variant (47840MO0010001-00) have Out of Service Area Coverage?
Yes. Details: Emergency Only
Does (47840MO0010001) Health Insurance Plan, Variant (47840MO0010001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy
Does WellFirst Gold Copay Plus 1500X Health Insurance Plan, Variant (47840MO0010001-00) offer Disease Management Programs for Asthma?
Yes, the WellFirst Gold Copay Plus 1500X Health Insurance Plan Variant
47840MO0010001-00 offers Disease
Management Program for Asthma.
Does WellFirst Gold Copay Plus 1500X Health Insurance Plan, Variant (47840MO0010001-00) offer Disease Management Programs for Heart disease?
Yes, the WellFirst Gold Copay Plus 1500X Health Insurance Plan Variant
47840MO0010001-00 offers Disease
Management Program for Heart disease.
Does WellFirst Gold Copay Plus 1500X Health Insurance Plan, Variant (47840MO0010001-00) offer Disease Management Programs for Diabetes?
Yes, the WellFirst Gold Copay Plus 1500X Health Insurance Plan Variant
47840MO0010001-00 offers Disease
Management Program for Diabetes.
Does WellFirst Gold Copay Plus 1500X Health Insurance Plan, Variant (47840MO0010001-00) offer Disease Management Programs for Pregnancy?
Yes, the WellFirst Gold Copay Plus 1500X Health Insurance Plan Variant
47840MO0010001-00 offers Disease
Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Tue, 16 Apr 2024 06:19 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