HDHP Preventive Silver 5500 $0 Select Drugs - 54192IN0010033 Health Insurance Plan
CareSource Indiana, Inc. health insurance plan with the Plan ID 54192IN0010033. The plan is called HDHP Preventive Silver 5500 $0 Select Drugs.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.18% (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 29.82% 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 | 54192IN0010033 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 54192IN0010033-03 | ||||||||||||||||||
| 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 - 54192IN0010033-00 Standard On Exchange Plan - 54192IN0010033-01 Open to Indians below 300% FPL - 54192IN0010033-02 Open to Indians above 300% FPL - 54192IN0010033-03 73% AV Silver Plan - 54192IN0010033-04 |
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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 HDHP Preventive Silver 5500 $0 Select Drugs Health Insurance Plan, 54192IN0010033-03
| 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 | No Charge after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Cost share driven by provider/setting |
YES | No Charge 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 | No Charge 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 | No Charge after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge after deductible |
100.00% |
| Dialysis
|
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
One wig per benefit period. |
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge 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 | No Charge after deductible |
No Charge 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 | No Charge after deductible |
100.00% |
| Generic Drugs
Select Preventive Drugs and Supplies are covered at no charge. Refer to the plan brochure for more information. |
YES | No Charge after deductible |
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 | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Hospice Services
|
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Cost share driven by provider/setting |
YES | No Charge 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 | No Charge 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 | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost share driven by provider/setting |
YES | No Charge after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
Cost share driven by provider/setting |
YES | No Charge after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge 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 | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | No Charge after deductible |
100.00% |
| Private-Duty Nursing
Limit: 100.0 Visit(s) per Year A visit equals 8 hours. |
YES | No Charge after deductible |
100.00% |
| Prosthetic Devices
|
YES | No Charge after deductible |
100.00% |
| Radiation
Cost share driven by provider/setting |
YES | No Charge 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 | No Charge 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 | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Benefit Period Cost share driven by provider/setting |
YES | No Charge 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 |
YES | 0.00% |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 90.0 Days per Benefit Period |
YES | No Charge after deductible |
100.00% |
| Specialist Visit
|
YES | No Charge after deductible |
100.00% |
| Specialty Drugs
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Cost share driven by provider/setting |
YES | No Charge after deductible |
100.00% |
| Transplant
Quantitative limit units apply, see Summary of Benefits and Coverage. |
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
No Charge after deductible |
| 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 | No Charge after deductible |
100.00% |
Preventive Silver Limited 5500 $0 Select Drugs Health Insurance Plan Variant 54192IN0010033-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.701750138662782 |
| 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 | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | INF012 |
| Formulary URL | URL |
| HIOS Product ID | 54192IN001 |
| 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 | New |
| 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 | Silver |
| 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) | 54192IN0010033-03 |
| Plan Marketing Name | HDHP Preventive Silver 5500 $0 Select Drugs |
| Plan Type | HMO |
| Plan Variant Marketing Name | Preventive Silver Limited 5500 $0 Select Drugs |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $5,500 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $1,500 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | INS001 |
| Source Name | HIOS |
| Plan ID | 54192IN0010033 |
| State Code | IN |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $11000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $5500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $5,500 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $11000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $5500 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $5,500 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $11000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,500 |
| 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 | $11000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $5500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,500 |
| 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 HDHP Preventive Silver 5500 $0 Select Drugs Health Insurance Plan, 54192IN0010033
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about HDHP Preventive Silver 5500 $0 Select Drugs, 54192IN0010033 Health Insurance Plan, 54192IN0010033
-
Does HDHP Preventive Silver 5500 $0 Select Drugs Health Insurance Plan, 54192IN0010033 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (54192IN0010033) Health Insurance Plan, Variant (54192IN0010033-03) offer Disease Management Programs?
Does (54192IN0010033) Health Insurance Plan, Variant (54192IN0010033-03) have Out Of Country Coverage?
Does (54192IN0010033) Health Insurance Plan, Variant (54192IN0010033-03) have Out of Service Area Coverage?
Does (54192IN0010033) Health Insurance Plan, Variant (54192IN0010033-03) offer Disease Management Programs?
Does Preventive Silver Limited 5500 $0 Select Drugs Health Insurance Plan, Variant (54192IN0010033-03) offer Disease Management Programs for Asthma?
Does Preventive Silver Limited 5500 $0 Select Drugs Health Insurance Plan, Variant (54192IN0010033-03) offer Disease Management Programs for Heart disease?
Does Preventive Silver Limited 5500 $0 Select Drugs Health Insurance Plan, Variant (54192IN0010033-03) offer Disease Management Programs for Depression?
Does Preventive Silver Limited 5500 $0 Select Drugs Health Insurance Plan, Variant (54192IN0010033-03) offer Disease Management Programs for Diabetes?
Does Preventive Silver Limited 5500 $0 Select Drugs Health Insurance Plan, Variant (54192IN0010033-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Preventive Silver Limited 5500 $0 Select Drugs Health Insurance Plan, Variant (54192IN0010033-03) offer Disease Management Programs for Low back pain?
Does Preventive Silver Limited 5500 $0 Select Drugs Health Insurance Plan, Variant (54192IN0010033-03) 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