Diabetes Gold 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness - 54192IN0020026 Health Insurance Plan
CareSource Indiana, Inc. health insurance plan with the Plan ID 54192IN0020026. The plan is called Diabetes Gold 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.96% (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 18.04% 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 | 54192IN0020026 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Indiana | ||||||||||||||||||
| Health Insurance Issuer | CareSource Indiana, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 54192IN0020026-03 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| 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 | Standard Off Exchange Plan - 54192IN0020026-00 Standard On Exchange Plan - 54192IN0020026-01 |
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| Last Plan Update Date | Fri, 13 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Diabetes Gold 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness Health Insurance Plan, 54192IN0020026-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Limit: 3000.0 Dollars per Episode Injury as a result of chewing or biting is not considered an accidental injury. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Cost share driven by provider/setting |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Cost share driven by provider/setting |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Benefit Period Manipulation Therapy is limited to 12 visits. Physical Therapy is limited to 20 visits. Physical Therapy imits are combined with services delivered under Outpatient Rehab or Habilitation Services. |
YES | $40.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | $500.00 Copay after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
One wig per benefit period. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | $500.00 Copay after deductible |
$500.00 Copay after deductible |
| Emergency Transportation/Ambulance
Ambulance transports must be made to the closest local facility that can provide you with covered services appropriate for your medical condition. |
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Limited to one pair of glasses or contact lenses per benefit year. |
YES | 0.00% |
100.00% |
| Gender Affirming Care
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Select Diabetic Drugs and Supplies are covered at no charge. Refer to the plan brochure for more information. |
YES | $2.00 |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Benefit Period Physical Therapy, Occupational Therapy, and Speech Therapy limited to 20 visits each per benefit period. |
YES | $10.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period A visit equals at least 4 hours. Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hospice 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
Cost share driven by provider/setting |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). |
YES | $500.00 Copay per Stay after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Cost share driven by provider/setting |
YES | $30.00 |
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 | $500.00 Copay per Stay after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost share driven by provider/setting |
YES | $10.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Cost share driven by provider/setting |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $10.00 |
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 Benefit Period Physical, Occupational, and Speech Therapy (including Post Cochlear Rehab) limited to 20 visits each. Cardiac Rehabilitation limited to 36 visits. Manipulation Therapy is limited to 12 visits. Pulmonary Therapy limited to 20 visits, except if rendered as part of Physical Therapy, the Physical Therapy visit limit will apply. Benefit also includes Physical Medicine and Rehabilitation Day Rehabilitation Therapy services on an Outpatient basis. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services. |
YES | 30.00% Coinsurance after deductible |
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
|
YES | $40.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $10.00 |
100.00% |
| Private-Duty Nursing
Limit: 100.0 Visit(s) per Year A visit equals 8 hours. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Radiation
Cost share driven by provider/setting |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: Excludes all other reconstructive services that are not specifically outlined in Covered Services. Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Benefit Period Physical Therapy and Occupational Therapy limited to 20 visits each per benefit period. |
YES | $10.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Benefit Period Cost share driven by provider/setting |
YES | $10.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 2.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | 0.00% |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 90.0 Days per Benefit Period |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $40.00 |
100.00% |
| Specialty Drugs
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $500.00 Copay per Stay after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Cost share driven by provider/setting |
YES | $10.00 |
100.00% |
| Transplant
Quantitative limit units apply, see Summary of Benefits and Coverage. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $30.00 |
$30.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
Cost share driven by provider/setting |
YES | 30.00% Coinsurance after deductible |
100.00% |
Diabetes Gold Limited 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness Health Insurance Plan Variant 54192IN0020026-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.819593398215053 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 0.9949614827079859 |
| First Tier Utilization | 100% |
| Formulary ID | INF008 |
| Formulary URL | URL |
| HIOS Product ID | 54192IN002 |
| Import Date | 2024-09-13 01:01:48 |
| 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 | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 54192 |
| Issuer Marketplace Marketing Name | CareSource |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | INN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services Only |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 54192IN0020026-03 |
| Plan Marketing Name | Diabetes Gold 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness |
| Plan Type | HMO |
| Plan Variant Marketing Name | Diabetes Gold Limited 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $500 |
| SBC Scenario, Having a Baby, Deductible | $1,100 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $50 |
| 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 | $1,100 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | INS001 |
| Source Name | HIOS |
| Plan ID | 54192IN0020026 |
| State Code | IN |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $15000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $7500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $7,500 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $2200 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $1100 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $1,100 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $2200 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1100 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,100 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $15000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,500 |
| 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 | Yes |
Copay & Coinsurance of Diabetes Gold 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness Health Insurance Plan, 54192IN0020026
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Diabetes Gold 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness, 54192IN0020026 Health Insurance Plan, 54192IN0020026
-
Does Diabetes Gold 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness Health Insurance Plan, 54192IN0020026 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (54192IN0020026) Health Insurance Plan, Variant (54192IN0020026-03) offer Disease Management Programs?
Does (54192IN0020026) Health Insurance Plan, Variant (54192IN0020026-03) have Out Of Country Coverage?
Does (54192IN0020026) Health Insurance Plan, Variant (54192IN0020026-03) have Out of Service Area Coverage?
Does (54192IN0020026) Health Insurance Plan, Variant (54192IN0020026-03) offer Disease Management Programs?
Does Diabetes Gold Limited 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness Health Insurance Plan, Variant (54192IN0020026-03) offer Disease Management Programs for Asthma?
Does Diabetes Gold Limited 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness Health Insurance Plan, Variant (54192IN0020026-03) offer Disease Management Programs for Heart disease?
Does Diabetes Gold Limited 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness Health Insurance Plan, Variant (54192IN0020026-03) offer Disease Management Programs for Depression?
Does Diabetes Gold Limited 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness Health Insurance Plan, Variant (54192IN0020026-03) offer Disease Management Programs for Diabetes?
Does Diabetes Gold Limited 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness Health Insurance Plan, Variant (54192IN0020026-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Diabetes Gold Limited 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness Health Insurance Plan, Variant (54192IN0020026-03) offer Disease Management Programs for Low back pain?
Does Diabetes Gold Limited 1100 $0 Select Drugs & Specialized Services Adult Vision & Fitness Health Insurance Plan, Variant (54192IN0020026-03) offer Disease Management Programs for Pregnancy?
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