Prestige Gold 50 + 1 Free PCP Visit - 81413WI0490016 Health Insurance Plan
Network Health Plan health insurance plan with the Plan ID 81413WI0490016. The plan is called Prestige Gold 50 + 1 Free PCP Visit.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.42% (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 19.58% 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 | 81413WI0490016 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Network Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 81413WI0490016-00 | ||||||||||||||||||
| Provider Network(s) | ['WIN001'] | ||||||||||||||||||
| 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 - 81413WI0490016-00 Standard On Exchange Plan - 81413WI0490016-01 |
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| Last Plan Update Date | Fri, 08 Nov 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Prestige Gold 50 + 1 Free PCP Visit Health Insurance Plan, 81413WI0490016-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Intravenous chemotherapy is covered. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Will cover 20 DME devices/items per year, whether rented or purchased in accordance with the requirements set out in the Policy. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Eye Glasses for Children
1 Item per year |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Adherence Generics are available at $0 copay or 0% coinsurance after deductible for certain categories of medications. |
YES | $15.00 |
100.00% |
| Habilitation Services
Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Covers the cost of basic hearing aids limited to one hearing aid per ear, including repair or replacement, once every three years. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
A lower copay/coinsurance applies to certain labs for condition management of chronic diseases. |
YES | 50.00% 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
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
The cost sharing displayed applies to outpatient office visits only. All other outpatient services may be subject to different cost sharing. Please refer to the plan policy documents for detailed information. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Rehabilitative services must be short term. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $50.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Prescription Drugs Other
Formulary Tier 5: Non-preferred specialty drugs |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Virtual Visits $0, Telehealth same cost share of in person visit |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Covers up to 10 prosthetic devices that replace a limb or a body part each Benefit Year. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Limited to 20 visits per benefit year for each: Occupational and Physical therapy. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Rehabilitative services must be short term. Limited to 20 visits per benefit year for each: Speech therapy. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
1 Exam per year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Stay |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Virtual Visits $0, Telehealth same cost share of in person visit |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Specialty Drugs
There is No Cost for covered Specialty Drugs for the Native American/Alaskan Limited and Zero Cost share plans. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
The cost sharing displayed applies to outpatient office visits only. All other outpatient services may be subject to different cost sharing. Please refer to the plan policy documents for detailed information. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Transplant
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Coverage for diagnostic procedures and non-surgical treatment limited to 10 services and/or devices per Benefit Year. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
Urgent Care Outside the Service Area is only covered when furnished by an Emergency room or Hospital-based Urgent Care Facility. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Prestige Gold 50 + 1 Free PCP Visit Health Insurance Plan Variant 81413WI0490016-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.804189703528925 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 1 |
| 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 |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | WIF001 |
| Formulary URL | URL |
| HIOS Product ID | 81413WI049 |
| Import Date | 2024-11-08 00:01:39 |
| 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 | 81413 |
| Issuer Marketplace Marketing Name | Network Health |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | WIN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services or Urgent Care Services When services are performed in a free standing urgent care facility or hospital based urgent care |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services or Urgent Care Services When services are performed in a free standing urgent care facility or hospital based urgent care |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 81413WI0490016-00 |
| Plan Marketing Name | Prestige Gold 50 + 1 Free PCP Visit |
| Plan Type | HMO |
| Plan Variant Marketing Name | Prestige Gold 50 + 1 Free PCP Visit |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,300 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $1,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,130 |
| SBC Scenario, Having Diabetes, Deductible | $790 |
| SBC Scenario, Having Diabetes, Limit | $60 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $900 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WIS002 |
| Source Name | HIOS |
| Plan ID | 81413WI0490016 |
| State Code | WI |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $2000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,000 |
| 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 | $8600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $4300 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $4,300 |
| 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 | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Prestige Gold 50 + 1 Free PCP Visit Health Insurance Plan, 81413WI0490016
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Prestige Gold 50 + 1 Free PCP Visit, 81413WI0490016 Health Insurance Plan, 81413WI0490016
-
Does Prestige Gold 50 + 1 Free PCP Visit Health Insurance Plan, 81413WI0490016 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (81413WI0490016) Health Insurance Plan, Variant (81413WI0490016-00) offer Disease Management Programs?
Does (81413WI0490016) Health Insurance Plan, Variant (81413WI0490016-00) have Out Of Country Coverage?
Does (81413WI0490016) Health Insurance Plan, Variant (81413WI0490016-00) have Out of Service Area Coverage?
Does (81413WI0490016) Health Insurance Plan, Variant (81413WI0490016-00) offer Disease Management Programs?
Does Prestige Gold 50 + 1 Free PCP Visit Health Insurance Plan, Variant (81413WI0490016-00) offer Disease Management Programs for Asthma?
Does Prestige Gold 50 + 1 Free PCP Visit Health Insurance Plan, Variant (81413WI0490016-00) offer Disease Management Programs for Heart disease?
Does Prestige Gold 50 + 1 Free PCP Visit Health Insurance Plan, Variant (81413WI0490016-00) offer Disease Management Programs for Diabetes?
Does Prestige Gold 50 + 1 Free PCP Visit Health Insurance Plan, Variant (81413WI0490016-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Prestige Gold 50 + 1 Free PCP Visit Health Insurance Plan, Variant (81413WI0490016-00) offer Disease Management Programs for Pregnancy?
Does Prestige Gold 50 + 1 Free PCP Visit Health Insurance Plan, Variant (81413WI0490016-00) 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