Covenant PHP Exclusive Gold 2000 25%
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
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.
Cost-sharing for Covenant PHP Exclusive Gold 2000 25% includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
Cost Sharing Type | Individual | Family |
---|---|---|
Out-of-Pocket Maximum: | $8,700.00 | $8700 per person | $17400 per group |
Deductible: | $2,000.00 | $2000 per person | $4000 per group |
Coinsurance: | 25.00% |
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Covenant PHP Exclusive Gold 2000 25% will be shown below if applicable.
Cost Sharing Type | Individual | Family |
---|---|---|
Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
Out-of-Network Deductible: | Not Applicable | per person not applicable | per group not applicable |
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
Deductible: | $2,000.00 |
Copayment: | $0.00 |
Coinsurance: | $2,600.00 |
Limit: | $60.00 |
Deductible: | $400.00 |
Copayment: | $1,000.00 |
Coinsurance: | $0.00 |
Limit: | $500.00 |
Deductible: | $2,000.00 |
Copayment: | $200.00 |
Coinsurance: | $100.00 |
Limit: | $5.00 |
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.
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.
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
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 |
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