Covenant PHP Exclusive Gold 2000 25%

60829MI0190037
Gold
HMO

Covenant PHP Exclusive Gold 2000 25% is a Gold HMO plan by Physicians Health Plan.

IMPORTANT: You are viewing the 2023 version of Covenant PHP Exclusive Gold 2000 25% 60829MI0190037. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Covenant PHP Exclusive Gold 2000 25% is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Covenant PHP Exclusive Gold 2000 25% 60829MI0190037.
Insurer: Physicians Health Plan
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 60829MI0190037

Cost-Sharing Overview

Covenant PHP Exclusive Gold 2000 25% offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Covenant PHP Exclusive Gold 2000 25%?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Covenant PHP Exclusive Gold 2000 25% offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Covenant PHP Exclusive Gold 2000 25% covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Coverage for emergency and urgent care only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Coverage only for emergency health services and urgent care center visits at network benefit level
National Network: No

Additional Benefits and Cost-Sharing

Covenant PHP Exclusive Gold 2000 25% includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 100.00%
Specialist Visit
Covered
$60.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 100.00% Elective abortion as defined by the State of Michigan is excluded. Female surgical sterilization is covered with no cost share if using network providers.
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 100.00% Elective abortion as defined by the State of Michigan is excluded. Female surgical sterilization is covered with no cost share if using network providers.
Hospice Services
Covered
25.00% Coinsurance after deductible 100.00%45 Days per Year Custodial care. Private duty nursing services are covered services only when provided coverage includes hospice care in a facility and home. Hospice facility services are limited to 45 days per contract year. Prior approval required.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
25.00% Coinsurance after deductible 100.00% Services and treatment to conceive a pregnancy are excluded. Underlying causes only.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$45.00 $45.00 Urgent care center visits are always covered at network benefit level.
Home Health Care Services
Covered
25.00% Coinsurance after deductible 100.00% Prior approval required.
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible Emergency Department visits are always covered at network benefit level. Approval required if admitted as inpatient.
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible Emergency ambulance services are always covered at network benefit level.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 100.00% Prior approval required.
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
50.00% Coinsurance after deductible 100.00%1 Procedure(s) per Lifetime Prior approval required.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 100.00%45 Days per Year Custodial care, private duty nursing Prior approval required.
Prenatal and Postnatal Care
Covered
25.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 100.00% Approval required if stay is longer than federal minimum time frames.
Mental/Behavioral Health Outpatient Services
Covered
$30.00 100.00% Prior approval required for all non-routine services.
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00% Prior approval required.
Substance Abuse Disorder Outpatient Services
Covered
$30.00 100.00% Prior approval required for all non-routine services.
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00% Prior approval required.
Generic Drugs
Covered
$15.00 100.00%
Preferred Brand Drugs
Covered
$30.00 100.00%
Non-Preferred Brand Drugs
Covered
$60.00 100.00%
Specialty Drugs
Covered
$250.00 100.00% Prior approval required on selected drugs. All specialty drugs are only available in up to 31-day supply from CVS mail-order specialty pharmacy.
Outpatient Rehabilitation Services
Covered
$30.00 100.00%30 Visit(s) per Year PT/OT – combined visits per contract year; 30 ST per contract year; 30 cardiac/pulmonary visits per contract year.
Habilitation Services
Covered
$30.00 100.00%30 Visit(s) per Year Yearly limits: PT and OT: 30 visits, Speech: 30 visits.
Chiropractic Care
Covered
$30.00 Copay after deductible 100.00%30 Visit(s) per Year
Durable Medical Equipment
Covered
50.00% 100.00% Certain DME items require prior approval. Please call PHP.
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Covered
50.00% Coinsurance after deductible 100.00%
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
25.00% Coinsurance after deductible 100.00%1 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$30.00 100.00%30 Visit(s) per Year Prior approval required.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 100.00%30 Visit(s) per Year
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
25.00% Coinsurance after deductible 100.00% Must be done at Designated Facility. Prior approval required.
Accidental Dental
Covered
$60.00 100.00% Approval required prior to follow-up care
Dialysis
Covered
25.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
50.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
25.00% Coinsurance after deductible 100.00%
Radiation
Covered
25.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
25.00% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
50.00% 100.00% Prior approval required if cost over $1,000.
Infusion Therapy
Covered
25.00% Coinsurance after deductible 100.00% Prior approval required.
Treatment for Temporomandibular Joint Disorders
Covered
50.00% Coinsurance after deductible 100.00% Coverage includes medical care or services to treat dysfunction or TMJS resulting from a medical cause or injury, Office visits for medical evaluation and treatment, X-rays of the temporomandibular joint including contrast studies, but not dental X-rays, Myofunctional therapy and Surgery to the temporomandibular joint, such as condylectomy, meniscectomy, arthrotomy, and arthrocentesis. Prior approval required
Nutritional Counseling
Covered
25.00% Coinsurance after deductible 100.00% Prior approval required.
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 100.00% Prior approval required
Gender Affirming Care
Covered
25.00% Coinsurance after deductible 100.00% Prior approval required
Autism Spectrum Disorders
Covered
25.00% Coinsurance after deductible 100.00% Prior approval required
Clinical Trials
Covered
25.00% Coinsurance after deductible 100.00% Prior approval required
Dental Anesthesia
Covered
50.00% Coinsurance after deductible 100.00% Routine Dental procedures not covered Prior approval required
Mental Health – Intermediate
Covered
25.00% Coinsurance after deductible 100.00% Prior approval required.
Substance Use Disorders – Intermediate
Covered
25.00% Coinsurance after deductible 100.00% Prior approval required.
Telemedicine Services
Covered
$30.00 100.00%
Non-Preferred Specialty Drugs
Not Covered
Prior approval required on selected drugs. All specialty drugs are only available in up to 31-day supply from CVS mail-order specialty pharmacy.
Preferred Generic Drugs
Not Covered
Tier 1A preferred generic drugs have the lowest copay (see SBC) and are available from a network retail pharmacy in up to a 90-day supply

Free Preventive Services

There is no copayment or coinsurance for any of the following Covenant PHP Exclusive Gold 2000 25% preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Covenant PHP Exclusive Gold 2000 25% including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Covenant PHP Exclusive Gold 2000 25%?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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