EMI Health Advantage Co-Pay - 20545IL0040003 Health Insurance Plan

Companion Life Insurance Company health insurance plan with the Plan ID 20545IL0040003. The plan is called EMI Health Advantage Co-Pay.

Health Insurance Plan ID 20545IL0040003
Health Insurance Plan Year 2025
State Illinois
Health Insurance Issuer Companion Life Insurance Company
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 20545IL0040003-01
Provider Network(s) PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 17 Dec 2024 06:12 GMT).

Providers Illinois All US States
All 1850 2141
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists 1084 1264
Available Variants of the Health Plan

Standard On Exchange Plan - 20545IL0040003-01

Last Plan Update Date Mon, 12 Aug 2024 00:00 GMT
Last Import Date Tue, 17 Dec 2024 06:12 GMT

Benefits of EMI Health Advantage Co-Pay Health Insurance Plan, 20545IL0040003-01

Benefit Covered In Network Out Of Network
Accidental Dental
NO
Basic Dental Care - Adult

Exclusions: Space Maintainers not covered after the end of the month the enrollee turns age 19. Fillings on the same surface 1 every 18 months. Basic benefits covered after 6 month waiting period.

Copays listed are average copays for this benefit category. For detailed copays by service please reference the copay schedule linked to the Advantage Copay plan brochure. Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.

YES

$86.00 Copay after deductible

$219.00 Copay after deductible
Basic Dental Care - Child

Exclusions: Space Maintainers not covered after the end of the month the enrollee turns age 19.

Copays listed are average copays for this benefit category. For detailed copays by service please reference the copay schedule linked to the Advantage Copay plan brochure. Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.

YES

$91.00 Copay after deductible

$228.00 Copay after deductible
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

Exams and cleanings limited to one every 6 months per dentist in an office setting and one every 12 months in a school setting. Bitewing X-rays up to 4 films twice a year. Panoramic X-Ray is allowed 1 every 3 years. Fluoride is allowed 3 per year for ages 0-6 or during orthodontic treatment. Fluoride is allowed 2 per year for ages 3 up to age 19. Sealants are covered 1 per tooth every 36 months. Fluoride and Sealants not covered after the end of the month the enrollee turns age 19. Copays listed are average copays for this benefit category. For detailed copays by service please reference the copay schedule linked to the Advantage Copay plan brochure. Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.

YES

No Charge after deductible

$28.00 Copay after deductible
Major Dental Care - Adult

Exclusions: Anesthesia only covered when medically or dentally necessary. Implants are not covered. Crowns, Pontics, Abutments, Onlays and Dentures are covered 1 every 5 years per tooth. Waiting period applies.

Copays listed are average copays for this benefit category. For detailed copays by service please reference the copay schedule linked to the Advantage Copay plan brochure. Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.

YES

$213.00 Copay after deductible

$513.00 Copay after deductible
Major Dental Care - Child

Exclusions: Anesthesia is only covered when medically or dentally necessary. Implants are not covered. Crowns, Pontics, Abutments, Onlays and Dentures are covered 1 every 5 years per tooth.

Copays listed are average copays for this benefit category. For detailed copays by service please reference the copay schedule linked to the Advantage Copay plan brochure. Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.

YES

$92.00 Copay after deductible

$210.00 Copay after deductible
Orthodontia - Adult
NO
Orthodontia - Child

Exclusions: Covered up to the end of the month the enrollee turns age 19.

Only Medically Necessary Ortho is covered. Benefits illustrated are in summary only. Refer to the plan brochure for additional details.

YES

50.00%

50.00%
Routine Dental Services (Adult)

Limit: 1.0 Visit(s) per 6 Months

Exams and cleanings limited to one every 6 months per dentist in an office setting and one every 12 months in a school setting. Bitewing X-rays up to 4 films twice a year. Panoramic X-Ray is allowed 1 every 3 years. Fluoride and Sealants not covered after the end of the month the enrollee turns age 19. Copays listed are average copays for this benefit category. For detailed copays by service please reference the copay schedule linked to the Advantage Copay plan brochure. Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.

YES

No Charge after deductible

$32.00 Copay after deductible

EMI Health Advantage Co-Pay Health Insurance Plan Variant 20545IL0040003-01 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 2025
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Low On Exchange Plan
Dental Only Plan Yes
EHB Apportionment for Pediatric Dental 1.0
First Tier Utilization 100%
HIOS Product ID 20545IL004
Import Date 2024-08-12 20:01:40
Inpatient Copayment Maximum Days 0
Guaranteed Rate Guaranteed Rate
New/Existing Plan Existing
Issuer ID 20545
Issuer Marketplace Marketing Name Companion Life Insurance Company
Market Coverage Individual
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group $850 per group
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person $425 per person
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out $425
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 per group not applicable
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person per person not applicable
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual Not Applicable
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 ILN002
Out of Country Coverage Yes
Out of Country Coverage Description Dental expenses for care, supplies, or services which are rendered by a Provider whose principal place of business or address for payment is located outside the United States are payable under the Plan, subject to all Plan exclusions, limitations, maximums and other provisions, under the conditions outlined in the policy.
Out of Service Area Coverage Yes
Out of Service Area Coverage Description PPO network or out-of-network coverage at PPO fee
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 20545IL0040003-01
Plan Marketing Name EMI Health Advantage Co-Pay
Plan Type PPO
Plan Variant Marketing Name EMI Health Advantage Co-Pay
QHP/Non QHP On the Exchange
Service Area ID ILS001
Source Name SERFF
Plan ID 20545IL0040003
State Code IL
URL for Enrollment Payment URL

Copay & Coinsurance of EMI Health Advantage Co-Pay Health Insurance Plan, 20545IL0040003

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

Frequently Asked Questions(FAQ) about EMI Health Advantage Co-Pay, 20545IL0040003 Health Insurance Plan, 20545IL0040003

  • Does EMI Health Advantage Co-Pay Health Insurance Plan, 20545IL0040003 support Mail Ordering?

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

  • Does (20545IL0040003) Health Insurance Plan, Variant (20545IL0040003-01) have Out Of Country Coverage?

    Yes. Details: Dental expenses for care, supplies, or services which are rendered by a Provider whose principal place of business or address for payment is located outside the United States are payable under the Plan, subject to all Plan exclusions, limitations, maximums and other provisions, under the conditions outlined in the policy.

    Does (20545IL0040003) Health Insurance Plan, Variant (20545IL0040003-01) have Out of Service Area Coverage?

    Yes. Details: PPO network or out-of-network coverage at PPO fee

 

Disclaimer: This is based on the import(Date: Tue, 17 Dec 2024 06:12 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