DentaTrust-PPO Family High Option - 58669AZ0010003 Health Insurance Plan
DentaTrust health insurance plan with the Plan ID 58669AZ0010003. The plan is called DentaTrust-PPO Family High Option.
| Health Insurance Plan ID | 58669AZ0010003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Arizona | ||||||||||||||||||
| Health Insurance Issuer | DentaTrust | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 58669AZ0010003-00 | ||||||||||||||||||
| Provider Network(s) | NULL | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Sat, 09 Sep 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of DentaTrust-PPO Family High Option Health Insurance Plan, 58669AZ0010003-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
Subject to a 6 month waiting period. See plan brochure for plan details and limitations and exclusions. |
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Basic Dental Care - Child
See plan brochure for plan details and limitations and exclusions. |
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months See plan brochure for plan details and limitations and exclusions. |
YES | No Charge |
No Charge |
| Major Dental Care - Adult
Subject to a 12 month waiting period. See plan brochure for plan details and limitations and exclusions. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Major Dental Care - Child
See plan brochure for plan details and limitations and exclusions. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Exclusions: Non-medically necessary orthodontic treatment will not be covered by the plan. See plan brochure for plan details and limitations and exclusions. |
YES | 50.00% |
50.00% |
| Routine Dental Services (Adult)
Limit: 1.0 Visit(s) per 6 Months See plan brochure for plan details and limitations and exclusions. |
YES | No Charge |
No Charge |
DentaTrust-PPO Family High Option Health Insurance Plan Variant 58669AZ0010003-00 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 | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard High Off Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 1.0 |
| First Tier Utilization | 100% |
| HIOS Product ID | 58669AZ001 |
| Import Date | 2023-09-09 01:01:59 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 58669 |
| Issuer Marketplace Marketing Name | DentaTrust |
| 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 | $800 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | $400 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $400 |
| 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 | High |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | AZN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Out-of-Network coverage is available for covered services obtained from non-participating dentists. See the schedule of benefits for out-of-network coverage levels. |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 58669AZ0010003-00 |
| Plan Level Exclusions | Please refer to the exclusions listed in the Plan Brochure for specific plan level exclusions. |
| Plan Marketing Name | DentaTrust-PPO Family High Option |
| Plan Type | PPO |
| Plan Variant Marketing Name | DentaTrust-PPO Family High Option |
| QHP/Non QHP | Both |
| Service Area ID | AZS001 |
| Source Name | HIOS |
| Plan ID | 58669AZ0010003 |
| State Code | AZ |
| URL for Enrollment Payment | URL |
Copay & Coinsurance of DentaTrust-PPO Family High Option Health Insurance Plan, 58669AZ0010003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about DentaTrust-PPO Family High Option, 58669AZ0010003 Health Insurance Plan, 58669AZ0010003
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Does DentaTrust-PPO Family High Option Health Insurance Plan, 58669AZ0010003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (58669AZ0010003) Health Insurance Plan, Variant (58669AZ0010003-00) have Out Of Country Coverage?
Does (58669AZ0010003) Health Insurance Plan, Variant (58669AZ0010003-00) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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