Managed DentalGuard IL30 Family Plan - 87304IL0050006 Health Insurance Plan
First Commonwealth Insurance Company health insurance plan with the Plan ID 87304IL0050006. The plan is called Managed DentalGuard IL30 Family Plan.
| Health Insurance Plan ID | 87304IL0050006 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Illinois | ||||||||||||||||||
| Health Insurance Issuer | First Commonwealth Insurance Company | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 87304IL0050006-00 | ||||||||||||||||||
| Provider Network(s) | ['ILN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Tue, 15 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 10 Dec 2024 06:32 GMT |
Benefits of Managed DentalGuard IL30 Family Plan Health Insurance Plan, 87304IL0050006-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
Patient charge listed is a sample copayment of basic service D2140 (amalgam - one surface, primary or permanent). A complete list of copayments can be obtained from the plan's benefit copayment schedule. Actual patient charges will vary based on procedure. Plan documents are the final arbiter of coverage. |
YES | $0.00 |
100.00% |
| Basic Dental Care - Child
Patient charge listed is a sample copayment of basic service D2140 (amalgam - one surface, primary or permanent). A complete list of copayments can be obtained from the plan's benefit copayment schedule. Actual patient charges will vary based on procedure but member responsibility for Pediatric Essential Benefits will not exceed the Maximum Out Of Pocket of $400 per child. Plan documents are the final arbiter of coverage. |
YES | $0.00 |
100.00% |
| Dental Check-Up for Children
Patient charge listed is a sample copayment of preventive service D0120 (Periodontic oral evalution - established patient). A complete list of copayments can be obtained from the plan's benefit copayment schedule. Actual patient charges will vary based on procedure but member responsibility for Pediatric Essential Benefits will not exceed the Maximum Out Of Pocket of $400 per child. Plan documents are the final arbiter of coverage. |
YES | $0.00 |
100.00% |
| Major Dental Care - Adult
Patient charge listed is a sample copayment of major service D2510 (Inlay - metallic - one surface). A complete list of copayments can be obtained from the plan's benefit copayment schedule. Actual patient charges will vary based on procedure. Plan documents are the final arbiter of coverage. |
YES | $265.00 |
100.00% |
| Major Dental Care - Child
Limitations vary based on procedures. |
YES | $265.00 |
100.00% |
| Orthodontia - Adult
Patient charge listed is a sample copayment of orthodontic service D8090 (Comprehensive orthodontic treatment of the adult dentition). A complete list of copayments can be obtained from the plan's benefit copayment schedule. Actual patient charges will vary based on procedure. Plan documents are the final arbiter of coverage. |
YES | $2,800.00 |
100.00% |
| Orthodontia - Child
Limitations vary based on procedures. |
YES | $400.00 |
100.00% |
| Routine Dental Services (Adult)
Patient charge listed is a sample copayment of preventive service D0120 (Periodontic oral evalution - established patient). A complete list of copayments can be obtained from the plan's benefit copayment schedule. Actual patient charges will vary based on procedure. Plan documents are the final arbiter of coverage. |
YES | $0.00 |
100.00% |
Managed DentalGuard IL30 Family Plan Health Insurance Plan Variant 87304IL0050006-00 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard High Off Exchange Plan |
| Dental Only Plan | Yes |
| First Tier Utilization | 100% |
| HIOS Product ID | 87304IL005 |
| Import Date | 2023-08-15 20:02:25 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 87304 |
| Issuer Marketplace Marketing Name | First Commonwealth Insurance Company |
| Market Coverage | SHOP (Small Group) |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out | Not Applicable |
| 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), Family Per Group | per group not applicable |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | per person not applicable |
| Medical EHB Deductible, In Network (Tier 1), Individual | Not Applicable |
| 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 |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group | $800 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | $400 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $400 |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual | Not Applicable |
| Metal Level | High |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | ILN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 87304IL0050006-00 |
| Plan Marketing Name | Managed DentalGuard IL30 Family Plan |
| Plan Type | HMO |
| Plan Variant Marketing Name | Managed DentalGuard IL30 Family Plan |
| QHP/Non QHP | Off the Exchange |
| Service Area ID | ILS002 |
| Source Name | SERFF |
| Plan ID | 87304IL0050006 |
| State Code | IL |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
Copay & Coinsurance of Managed DentalGuard IL30 Family Plan Health Insurance Plan, 87304IL0050006
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Managed DentalGuard IL30 Family Plan, 87304IL0050006 Health Insurance Plan, 87304IL0050006
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Does Managed DentalGuard IL30 Family Plan Health Insurance Plan, 87304IL0050006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (87304IL0050006) Health Insurance Plan, Variant (87304IL0050006-00) have Out Of Country Coverage?
Does (87304IL0050006) Health Insurance Plan, Variant (87304IL0050006-00) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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