Healthy Premier Silver Copay - 42261UT0060002 Health Insurance Plan
University of Utah Health Insurance Plans health insurance plan with the Plan ID 42261UT0060002. The plan is called Healthy Premier Silver Copay.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.58% (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 5.42% 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 | 42261UT0060002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 42261UT0060002-06 | ||||||||||||||||||
| 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 - 42261UT0060002-00 Standard On Exchange Plan - 42261UT0060002-01 Open to Indians below 300% FPL - 42261UT0060002-02 Open to Indians above 300% FPL - 42261UT0060002-03 73% AV Silver Plan - 42261UT0060002-04 |
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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 Silver Copay Health Insurance Plan, 42261UT0060002-06
| 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 | 10.00% |
100.00% |
| Autism Spectrum Disorders
|
YES | 10.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 10.00% |
100.00% |
| Chiropractic Care
|
NO | ||
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 10.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Must be for the diagnosis of diabetes. |
YES | 10.00% |
100.00% |
| Dialysis
|
YES | 10.00% |
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 | 10.00% |
100.00% |
| Emergency Room Services
|
YES | $100.00 |
$100.00 |
| Emergency Transportation/Ambulance
|
YES | $250.00 |
$250.00 |
| 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 | $10.00 |
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 | 10.00% |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | 10.00% |
100.00% |
| Hospice Services
Requires Pre-authorization and Medical Case Management. |
YES | 10.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 10.00% |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 10.00% |
100.00% |
| Inherited Metabolic Disorder - PKU
|
YES | 10.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 10.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 10.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 10.00% |
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 | 10.00% |
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 | 10.00% |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Item(s) per Month |
YES | 45.00% |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $10.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 10.00% |
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 | 10.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 10.00% |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Item(s) per Month |
YES | $25.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 10.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $10.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 10.00% |
100.00% |
| Reconstructive Surgery
Covers mastectomy in the treatment of cancer and reconstructive surgery after a mastectomy. |
YES | 10.00% |
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 | 10.00% |
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 | 10.00% |
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 | 10.00% |
100.00% |
| Specialist Visit
|
YES | $20.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Item(s) per Month |
YES | 50.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
Requires Pre-authorization. |
YES | 10.00% |
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 | 10.00% |
100.00% |
| Transplant
|
YES | 10.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $10.00 |
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 | 10.00% |
100.00% |
Healthy Premier Silver Copay Health Insurance Plan Variant 42261UT0060002-06 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.9457955708231899 |
| 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 | 94% AV Level Silver Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 10.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 | UTF003 |
| 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 | $0 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 10.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 | Silver |
| 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) | 42261UT0060002-06 |
| Plan Level Exclusions | See Plan Document |
| Plan Marketing Name | Healthy Premier Silver Copay |
| Plan Type | EPO |
| Plan Variant Marketing Name | Healthy Premier Silver Copay |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,300 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $90 |
| SBC Scenario, Having Diabetes, Copayment | $400 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $70 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | UTS002 |
| Source Name | SERFF |
| Plan ID | 42261UT0060002 |
| State Code | UT |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $3000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $1500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $1,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $3000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $1500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $1,500 |
| 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 Healthy Premier Silver Copay Health Insurance Plan, 42261UT0060002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Healthy Premier Silver Copay, 42261UT0060002 Health Insurance Plan, 42261UT0060002
-
Does Healthy Premier Silver Copay Health Insurance Plan, 42261UT0060002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (42261UT0060002) Health Insurance Plan, Variant (42261UT0060002-06) offer Disease Management Programs?
Does (42261UT0060002) Health Insurance Plan, Variant (42261UT0060002-06) have Out Of Country Coverage?
Does (42261UT0060002) Health Insurance Plan, Variant (42261UT0060002-06) have Out of Service Area Coverage?
Does (42261UT0060002) Health Insurance Plan, Variant (42261UT0060002-06) offer Disease Management Programs?
Does Healthy Premier Silver Copay Health Insurance Plan, Variant (42261UT0060002-06) offer Disease Management Programs for Asthma?
Does Healthy Premier Silver Copay Health Insurance Plan, Variant (42261UT0060002-06) offer Disease Management Programs for Heart disease?
Does Healthy Premier Silver Copay Health Insurance Plan, Variant (42261UT0060002-06) offer Disease Management Programs for Depression?
Does Healthy Premier Silver Copay Health Insurance Plan, Variant (42261UT0060002-06) offer Disease Management Programs for Diabetes?
Does Healthy Premier Silver Copay Health Insurance Plan, Variant (42261UT0060002-06) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Healthy Premier Silver Copay Health Insurance Plan, Variant (42261UT0060002-06) offer Disease Management Programs for Low back pain?
Does Healthy Premier Silver Copay Health Insurance Plan, Variant (42261UT0060002-06) offer Disease Management Programs for Pregnancy?
Does Healthy Premier Silver Copay Health Insurance Plan, Variant (42261UT0060002-06) 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