Healthy Premier Gold Copay - 42261UT0060001 Health Insurance Plan
University of Utah Health Insurance Plans health insurance plan with the Plan ID 42261UT0060001. The plan is called Healthy Premier Gold Copay.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.83% (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 21.17% 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 | 42261UT0060001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 42261UT0060001-00 | ||||||||||||||||||
| 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 - 42261UT0060001-00 Standard On Exchange Plan - 42261UT0060001-01 |
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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 Gold Copay Health Insurance Plan, 42261UT0060001-00
| 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 | 20.00% Coinsurance after deductible |
100.00% |
| Autism Spectrum Disorders
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
|
NO | ||
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Must be for the diagnosis of diabetes. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 20.00% Coinsurance 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 | 20.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | $200.00 Copay after deductible |
$200.00 Copay after deductible |
| Emergency Transportation/Ambulance
|
YES | $250.00 Copay after deductible |
$250.00 Copay after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Lenses only. |
YES | No Charge |
No Charge |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Limit: 30.0 Item(s) per Month |
YES | $15.00 |
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 | 20.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Requires Pre-authorization and Medical Case Management. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inherited Metabolic Disorder - PKU
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 20.00% Coinsurance 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 | 20.00% Coinsurance 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 | 20.00% Coinsurance after deductible |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Item(s) per Month |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $25.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 20.00% Coinsurance 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 | 20.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Item(s) per Month |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $25.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Covers mastectomy in the treatment of cancer and reconstructive surgery after a mastectomy. |
YES | 20.00% Coinsurance 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 | 20.00% Coinsurance 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 | 20.00% Coinsurance 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 |
No Charge |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Visit(s) per Benefit Period Requires Pre-authorization and Medical Case Management. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $40.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Item(s) per Month |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Requires Pre-authorization. |
YES | 20.00% Coinsurance 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 | 20.00% Coinsurance after deductible |
100.00% |
| Transplant
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $25.00 |
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 | 20.00% Coinsurance after deductible |
100.00% |
Healthy Premier Gold Copay Health Insurance Plan Variant 42261UT0060001-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.788316902795741 |
| 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 | $1000 per group |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $500 per person |
| Drug EHB Deductible, Combined In/Out of Network, Individual | $500 |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $500 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $500 |
| 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, Weight Loss Programs |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | UTF001 |
| 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 ID | 42261 |
| Issuer Marketplace Marketing Name | University of Utah Health Plans |
| 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 | $3000 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $1500 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $1,500 |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| 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 | 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) | 42261UT0060001-00 |
| Plan Level Exclusions | See Plan Document |
| Plan Marketing Name | Healthy Premier Gold Copay |
| Plan Type | EPO |
| Plan Variant Marketing Name | Healthy Premier Gold Copay |
| 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 | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $600 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | UTS002 |
| Source Name | SERFF |
| Plan ID | 42261UT0060001 |
| State Code | UT |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $14000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $7000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $7,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $14000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,000 |
| 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 Healthy Premier Gold Copay Health Insurance Plan, 42261UT0060001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Healthy Premier Gold Copay, 42261UT0060001 Health Insurance Plan, 42261UT0060001
-
Does Healthy Premier Gold Copay Health Insurance Plan, 42261UT0060001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (42261UT0060001) Health Insurance Plan, Variant (42261UT0060001-00) offer Disease Management Programs?
Does (42261UT0060001) Health Insurance Plan, Variant (42261UT0060001-00) have Out Of Country Coverage?
Does (42261UT0060001) Health Insurance Plan, Variant (42261UT0060001-00) have Out of Service Area Coverage?
Does (42261UT0060001) Health Insurance Plan, Variant (42261UT0060001-00) offer Disease Management Programs?
Does Healthy Premier Gold Copay Health Insurance Plan, Variant (42261UT0060001-00) offer Disease Management Programs for Asthma?
Does Healthy Premier Gold Copay Health Insurance Plan, Variant (42261UT0060001-00) offer Disease Management Programs for Heart disease?
Does Healthy Premier Gold Copay Health Insurance Plan, Variant (42261UT0060001-00) offer Disease Management Programs for Depression?
Does Healthy Premier Gold Copay Health Insurance Plan, Variant (42261UT0060001-00) offer Disease Management Programs for Diabetes?
Does Healthy Premier Gold Copay Health Insurance Plan, Variant (42261UT0060001-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Healthy Premier Gold Copay Health Insurance Plan, Variant (42261UT0060001-00) offer Disease Management Programs for Low back pain?
Does Healthy Premier Gold Copay Health Insurance Plan, Variant (42261UT0060001-00) offer Disease Management Programs for Pregnancy?
Does Healthy Premier Gold Copay Health Insurance Plan, Variant (42261UT0060001-00) 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