Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access) - 36194FL0440003 Health Insurance Plan
Health First Commercial Plans, Inc. health insurance plan with the Plan ID 36194FL0440003. The plan is called Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.05% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.95% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 77.10% (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 22.90% 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 | 36194FL0440003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Florida | ||||||||||||||||||
| Health Insurance Issuer | Health First Commercial Plans, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 36194FL0440003-00 | ||||||||||||||||||
| Provider Network(s) | NATIONAL | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 36194FL0440003-00 Standard On Exchange Plan - 36194FL0440003-01 |
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| Last Plan Update Date | Sat, 19 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 24 Dec 2024 06:21 GMT |
Benefits of Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access) Health Insurance Plan, 36194FL0440003-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Coverage is limited to care and stabilization treatment rendered within 62 calendar days of an accidental dental injury. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $0.00 |
100.00% |
| Anesthesia Services for Dental Care
Includes general anesthesia and hospitalization services in connection with dental treatment provided in a hospital or ambulatory surgical center. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Covered up through the end of the birth month in which the covered person reaches age nineteen (19). |
YES | $0.00 |
100.00% |
| Cardiac and Pulmonary Rehabilitation
Limit: 36.0 Days per Lifetime |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 26.0 Visit(s) per Year |
YES | $50.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months Covered up through the end of the birth month in which the covered person reaches age nineteen (19). Basic and major dental care and orthodontic services. |
YES | $0.00 |
100.00% |
| Diabetes Education
In order to be covered, diabetes outpatient self-management training and educational services must be provided under the direct supervision of a certified diabetes educator or board certified physician specializing in endocrinology. |
YES | $0.00 |
100.00% |
| Dialysis
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Exclusions: Items that are primarily for convenience or comfort and items available over-the-counter are excluded. The replacement of equipment is also excluded, unless it is non-functional and not practically repairable. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
| Enteral/Parenteral and Oral Nutrition Therapy
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Covered up through the end of the birth month in which the covered person reaches age nineteen (19). |
YES | $0.00 |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Preferred Generic Drugs: $3 copay for 30 days' supply. |
YES | $15.00 |
100.00% |
| Genetic Testing Lab Services
BRCA Analysis to determine a woman's genetic risk for breast and ovarian cancer is covered as a preventive benefit when medical necessity criteria are met and authorized in advance by the health plan. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Habilitation Services
Limit: 35.0 Visit(s) per Year Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Combined limit for all outpatient habilitative physical, occupational and speech therapy. Limit applies per condition. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 60.0 Visit(s) per Year One date of service is equal to one visit. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Exclusions: Covered hospice services do not include bereavement counseling, pastoral counseling, financial or legal counseling or custodial care. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Hyperbaric Oxygen Therapy
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Cost-share applies per visit, per type |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Includes chemotherapy, infusions, therapeutic injections, allergy immunotherapy, and other medications ordered and administered by a provider. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Coverage for inpatient rehabilitation services are limited to 21 days per calendar year. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $0.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Covered up through the end of the birth month in which the covered person reaches age nineteen (19). |
YES | $0.00 |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
The cost-share that displays applies to Mental/Behavioral Health Outpatient Services only. For Mental Health Office Visit, the Mental Health Office Visit cost-share applies. Please refer to the plan policy documents for detailed information. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Mental Health Office Visit
Virtual Health provided as a means to receive this benefit. |
YES | $50.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $55.00 Copay after deductible |
100.00% |
| Nutritional Counseling
|
YES | $0.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Covered up through the end of the birth month in which the covered person reaches age nineteen (19). |
YES | $0.00 |
100.00% |
| Osteoporosis Treatment
Treatment provided at a primary care physician's office will be subject to the Primary Care Visit cost-share. |
YES | $50.00 |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Specialist Visit cost-share will apply if visit is in a specialist's office. |
YES | $25.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Outpatient Observation
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Combined limit for all outpatient rehabilitative physical, occupational and speech therapy. Limit applies per condition. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Partial Hospitalization
A structured program of active treatment for psychiatric care that is more intense than the care performed in a physician?s or therapist?s office. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $30.00 Copay after deductible |
100.00% |
| Preferred Generic Drugs
|
YES | $3.00 |
100.00% |
| Prenatal and Postnatal Care
Visits 16+ and visits with a perinatologist are subject to the Specialist Visit cost-share. Birthing classes are covered at $0 copay. |
YES | $0.00 |
100.00% |
| Preventive Care/Screening/Immunization
Limited to services recommended with an "A" or "B" rating by the U.S. Preventive Services Task Force (USPSTF), immunizations recommended for routine use by the Centers for Disease Control and Prevention (CDC), and services listed in guidelines of the Health Resources and Services Administration (HRSA) for women and children. |
YES | $0.00 |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Virtual Health provided as a means to receive this benefit. |
YES | $25.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Covered prosthetic devices (except cardiac pacemakers and prosthetic devices incident to a mastectomy) are limited to the first such permanent prosthesis, including the first temporary prosthesis if necessary, prescribed for each condition. Coverage is provided for necessary replacement of a prosthetic device owned by the enrollee when due to irreparable damage, wear, a change in the enrollee's condition, or when necessitated due to growth of a child. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Any cosmetic reconstructive surgery is excluded. Surgery performed outpatient is subject to the Outpatient Facility Fee and Outpatient Surgery Physician/Surgical Services cost-share. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Year Combined limit for all outpatient rehabilitative physical, occupational and speech therapy. Limit applies per condition. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Year Combined limit for all outpatient rehabilitative physical, occupational and speech therapy. Limit applies per condition. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Covered up through the end of the birth month in which the covered person reaches age nineteen (19). |
YES | $0.00 |
100.00% |
| Routine Foot Care
Routine foot care, including any service or supply in connection with foot care, is only covered when medically necessary. |
YES | $50.00 |
100.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Virtual Health provided as a means to receive this benefit. |
YES | $50.00 |
100.00% |
| Specialty Drugs
Coverage is limited to 30-day supply from preferred specialty pharmacy. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Office Visit
Virtual Health provided as a means to receive this benefit. |
YES | $50.00 |
100.00% |
| Transplant
Includes bone marrow transplant |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Limit: 1.0 Item(s) per 6 Months One splint in a six (6) month period is covered, unless a more frequent replacement is determined to be medically necessary. Splints are subject to the Durable Medical Equipment cost-share. Medically necessary outpatient surgical procedures are subject to the Outpatient Facility Fee and Outpatient Surgery Physician/Surgical Services cost-share. |
YES | 35.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
Virtual Health provided as a means to receive this benefit. Virtual Urgent Care copay $15. |
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 applies per visit, per type |
YES | 35.00% Coinsurance after deductible |
100.00% |
Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access) Health Insurance Plan Variant 36194FL0440003-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7709937263826441 |
| 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 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 | 25.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $400 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $200 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $200 |
| 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 |
| 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 | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | FLF005 |
| Formulary URL | URL |
| HIOS Product ID | 36194FL044 |
| Import Date | 2024-10-19 01:01:38 |
| 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 Actuarial Value | 78.05% |
| Issuer ID | 36194 |
| Issuer Marketplace Marketing Name | Health First Commercial Plans, Inc. |
| 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 | 35.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $4800 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $2400 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $2,400 |
| 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 | FLN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 36194FL0440003-00 |
| Plan Marketing Name | Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access) |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access) |
| 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 | $2,400 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $1,000 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,400 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | FLS002 |
| Source Name | HIOS |
| Plan ID | 36194FL0440003 |
| State Code | FL |
| 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 | $14600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7300 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,300 |
| 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 | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access) Health Insurance Plan, 36194FL0440003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access), 36194FL0440003 Health Insurance Plan, 36194FL0440003
-
Does Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access) Health Insurance Plan, 36194FL0440003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (36194FL0440003) Health Insurance Plan, Variant (36194FL0440003-00) offer Disease Management Programs?
Does (36194FL0440003) Health Insurance Plan, Variant (36194FL0440003-00) have Out Of Country Coverage?
Does (36194FL0440003) Health Insurance Plan, Variant (36194FL0440003-00) have Out of Service Area Coverage?
Does (36194FL0440003) Health Insurance Plan, Variant (36194FL0440003-00) offer Disease Management Programs?
Does Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access) Health Insurance Plan, Variant (36194FL0440003-00) offer Disease Management Programs for Asthma?
Does Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access) Health Insurance Plan, Variant (36194FL0440003-00) offer Disease Management Programs for Heart disease?
Does Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access) Health Insurance Plan, Variant (36194FL0440003-00) offer Disease Management Programs for Depression?
Does Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access) Health Insurance Plan, Variant (36194FL0440003-00) offer Disease Management Programs for Diabetes?
Does Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access) Health Insurance Plan, Variant (36194FL0440003-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access) Health Insurance Plan, Variant (36194FL0440003-00) offer Disease Management Programs for Low back pain?
Does Gold Savings 1825 ($25 Primary Care Copay, $50 Specialist Copay, Open Access) Health Insurance Plan, Variant (36194FL0440003-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 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