Healthy Premier Bronze HSA - 42261UT0060003 Health Insurance Plan
University of Utah Health Insurance Plans health insurance plan with the Plan ID 42261UT0060003. The plan is called Healthy Premier Bronze HSA.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 61.63% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 38.37% 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 61.36% (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 38.64% 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 | 42261UT0060003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | University of Utah Health Insurance Plans | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 42261UT0060003-03 | ||||||||||||||||||
| 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 - 42261UT0060003-00 Standard On Exchange Plan - 42261UT0060003-01 |
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| Last Plan Update Date | Tue, 13 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Healthy Premier Bronze HSA Health Insurance Plan, 42261UT0060003-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
NO | ||
| Acupuncture
|
NO | ||
| Allergy Testing
Charges for office visits in connection with repetitive injections are not covered. Sublingual or colorimetric allergy testing. |
YES | No Charge after deductible |
100.00% |
| Autism Spectrum Disorders
|
YES | No Charge after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
|
NO | ||
| 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
Must be for the diagnosis of diabetes. |
YES | No Charge after deductible |
100.00% |
| Dialysis
|
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
DME over $1000, rentals, that exceed 60 days, or as indicated in Appendix A of the Master Policy require Pre-authorization. |
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Lenses only. |
YES | 0.00% Coinsurance after deductible |
0.00% Coinsurance after deductible |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Limit: 30.0 Item(s) per Month |
YES | No Charge after deductible |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Benefit Period Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year |
YES | No Charge after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | No Charge after deductible |
100.00% |
| Hospice Services
Requires Pre-authorization and Medical Case Management. |
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | No Charge after deductible |
100.00% |
| Inherited Metabolic Disorder - PKU
|
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
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
Requires Pre-authorization. |
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Office Visits may be subject to a Copay, All other outpatient services are subject to the deductible and coinsurance. See your SBC for more details. |
YES | No Charge after deductible |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Item(s) per Month |
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
|
NO | ||
| 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: 20.0 Visit(s) per Benefit Period Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year |
YES | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Item(s) per Month |
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | No Charge after deductible |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
Covers mastectomy in the treatment of cancer and reconstructive surgery after a mastectomy. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Benefit Period Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Benefit Period Includes other outpatient rehabilitation services with a combined limit of 20 visits per plan year |
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 Visit(s) per Benefit Period |
YES | No Charge after deductible |
No Charge after deductible |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Visit(s) per Benefit Period Requires Pre-authorization and Medical Case Management. |
YES | No Charge after deductible |
100.00% |
| Specialist Visit
|
YES | No Charge after deductible |
100.00% |
| Specialty Drugs
Limit: 30.0 Item(s) per Month |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Requires Pre-authorization. |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Office Visits may be subject to a Copay, All other outpatient services are subject to the deductible and coinsurance. See your SBC for more details. |
YES | No Charge after deductible |
100.00% |
| Transplant
|
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Benefit should mirror preventive care/screening/immunization. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
100.00% |
Healthy Premier Bronze Health Insurance Plan Variant 42261UT0060003-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.6136009289871259 |
| 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, Weight Loss Programs |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | UTF011 |
| Formulary URL | URL |
| HIOS Product ID | 42261UT006 |
| Import Date | 2024-08-13 20:01:38 |
| 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 | 61.63% |
| Issuer ID | 42261 |
| Issuer Marketplace Marketing Name | University of Utah Health Plans |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | UTN001 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Emergent Only |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Emergent Only |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 42261UT0060003-03 |
| Plan Level Exclusions | See Plan Document |
| Plan Marketing Name | Healthy Premier Bronze HSA |
| Plan Type | EPO |
| Plan Variant Marketing Name | Healthy Premier Bronze |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $8,300 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,400 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| 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 | $2,400 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | UTS002 |
| Source Name | SERFF |
| Plan ID | 42261UT0060003 |
| State Code | UT |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $16600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $8300 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $8,300 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $16600 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $8300 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $8,300 |
| 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 | $16600 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $8300 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $8,300 |
| 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 | $16600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8300 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,300 |
| 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 | Yes |
Copay & Coinsurance of Healthy Premier Bronze HSA Health Insurance Plan, 42261UT0060003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Healthy Premier Bronze HSA, 42261UT0060003 Health Insurance Plan, 42261UT0060003
-
Does Healthy Premier Bronze HSA Health Insurance Plan, 42261UT0060003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (42261UT0060003) Health Insurance Plan, Variant (42261UT0060003-03) offer Disease Management Programs?
Does (42261UT0060003) Health Insurance Plan, Variant (42261UT0060003-03) have Out Of Country Coverage?
Does (42261UT0060003) Health Insurance Plan, Variant (42261UT0060003-03) have Out of Service Area Coverage?
Does (42261UT0060003) Health Insurance Plan, Variant (42261UT0060003-03) offer Disease Management Programs?
Does Healthy Premier Bronze Health Insurance Plan, Variant (42261UT0060003-03) offer Disease Management Programs for Asthma?
Does Healthy Premier Bronze Health Insurance Plan, Variant (42261UT0060003-03) offer Disease Management Programs for Heart disease?
Does Healthy Premier Bronze Health Insurance Plan, Variant (42261UT0060003-03) offer Disease Management Programs for Depression?
Does Healthy Premier Bronze Health Insurance Plan, Variant (42261UT0060003-03) offer Disease Management Programs for Diabetes?
Does Healthy Premier Bronze Health Insurance Plan, Variant (42261UT0060003-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Healthy Premier Bronze Health Insurance Plan, Variant (42261UT0060003-03) offer Disease Management Programs for Low back pain?
Does Healthy Premier Bronze Health Insurance Plan, Variant (42261UT0060003-03) offer Disease Management Programs for Pregnancy?
Does Healthy Premier Bronze Health Insurance Plan, Variant (42261UT0060003-03) offer Disease Management Programs for Weight loss programs?
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