High Plains Ind Gold Standard WY

38576WY0020008
Gold
PPO

High Plains Ind Gold Standard WY is a Gold PPO plan by Mountain Health CO-OP.

IMPORTANT: You are viewing the 2023 version of High Plains Ind Gold Standard WY 38576WY0020008. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

High Plains Ind Gold Standard WY is offered in the following counties.

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Plan Overview

This is a plan overview for 2023 version of High Plains Ind Gold Standard WY 38576WY0020008.
Insurer: Mountain Health CO-OP
Network Type: PPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 38576WY0020008

Cost-Sharing Overview

High Plains Ind Gold Standard WY 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 High Plains Ind Gold Standard WY?

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

High Plains Ind Gold Standard WY offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Diabetes
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 High Plains Ind Gold Standard WY covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergent Only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergent Only
National Network: No

Additional Benefits and Cost-Sharing

High Plains Ind Gold Standard WY 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 45.00% Coinsurance after deductible
Specialist Visit
Covered
$60.00 45.00% Coinsurance after deductible No referral needed for a specialist.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 45.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Hospice Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Pre-Certification is required. The Participant must be diagnosed with a terminal illness for which the attending Physician’s prognosis for life expectancy is estimated to be six (6) months or less.
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Inpatient Private Duty Nursing Services are Covered Services only in certain circumstances such as: The Participant?s Condition would ordinarily require that the Participant be placed in an intensive or coronary care unit, but the Hospital does not have such facilities.
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$45.00 45.00% Coinsurance after deductible
Home Health Care Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Pre-Certification is required. The need for Home Healthcare must be directly related to the Condition for which the Participant?s hospitalization was required.
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Pre-admission Review before being admitted as an Inpatient to a Hospital for non-maternity or non-emergency Conditions.
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Pre-admission Review before being admitted as an Inpatient to a Hospital for non-maternity or non-emergency Conditions.
Bariatric Surgery
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible1 Procedure(s) per Lifetime Pre-certification is required. Surgery for obesity will be a Covered Service only when required due to morbid obesity. The participant meets the current NIH (National Institutes of Health) surgical criteria.
Cosmetic Surgery
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Pre-Certification Required and subject to approval by Case Benefit Management. Care must begin within 14 days after discharge from the hospital or skilled nursing facility.
Prenatal and Postnatal Care
Covered
$30.00 45.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Includes professional services.
Mental/Behavioral Health Outpatient Services
Covered
$30.00 45.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
Covered
$30.00 45.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Generic Drugs
Covered
$15.00 45.00% Coinsurance after deductible
Preferred Brand Drugs
Covered
$30.00 45.00% Coinsurance after deductible
Non-Preferred Brand Drugs
Covered
$60.00 45.00% Coinsurance after deductible
Specialty Drugs
Covered
$250.00 45.00% Coinsurance after deductible Must be pre-approved.
Outpatient Rehabilitation Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible20 Visit(s) per Year Outpatient Rehabilitative Benefits are limited to a maximum of twenty (20) visits per calendar year per Participant.
Habilitation Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible20 Visit(s) per Year Outpatient Habilitative Benefits are limited to a maximum of twenty (20) visits per calendar year per Participant.
Chiropractic Care
Covered
$60.00 45.00% Coinsurance after deductible20 Visit(s) per Year Limited to 20 visits per calendar year.
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Some items require Pre-Certification. The rental or the purchase of durable medical equipment, whichever is less expensive, is a Covered Service. When a purchase is authorized, Benefits will also be provided for repair, maintenance, replacement, and adjustment of the equipment.
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
Covered
0.00% 45.00% Coinsurance after deductible
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge 25.00% Coinsurance after deductible1 Exam(s) per Year Covers one exam per calendar year subject to deductible and coinsurance.
Eye Glasses for Children
Covered
No Charge 25.00% Coinsurance after deductible1 Item(s) per Year Covers one pair of eyeglasses or 12 month supply of contacts per calendar year.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$30.00 45.00% Coinsurance after deductible20 Visit(s) per Year Outpatient is limited to 40 visits per calendar year for physical therapy and combined 20 visit per calendar year maximum for occupational therapy & speech therapy.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 45.00% Coinsurance after deductible60 Visit(s) per Year Outpatient is limited to 40 visits per calendar year for physical therapy and combined 20 visit per calendar year maximum for occupational therapy & speech therapy.
Well Baby Visits and Care
Covered
No Charge 45.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Pre-Admission Review is required prior to obtaining non-maternity and non-emergency Inpatient Human Organ Transplant services.
Accidental Dental
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Pediatric only – Restorations of the mouth, tooth, or jaw which are necessary due to an accidental injury are limited to those services, supplies, and appliances appropriate for dental needs. These are not pediatric only benefits. The section refers to some excluded services that are covered under Pediatric Dental but this section applies to all enrollees under the product.
Dialysis
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Allergy Testing
Chemotherapy
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Radiation
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Diabetes Education
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible1 Item(s) per Lifetime Covered Outpatient self-management training and education are limited to a one-time evaluation and training program when Medically Necessary, within one (1) year of diagnosis.
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Some items require Pre-Certification.
Infusion Therapy
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Pre-Certification Required. Reconstructive procedures which correct deformities of the jaw. Reconstructive Surgery is a Covered Service only where Participant?s Surgery is required as the result of a birth defect, accidental injury, or a malignant disease process or its treatment.
Gender Affirming Care
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible

Free Preventive Services

There is no copayment or coinsurance for any of the following High Plains Ind Gold Standard WY 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 High Plains Ind Gold Standard WY 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 High Plains Ind Gold Standard WY?

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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