Standard Gold 1500
14624MS0010007
Gold
POS
Standard Gold 1500 is a Gold POS plan by Primewell Health Services of Mississippi.
Locations
Standard Gold 1500 is offered in the following counties.
Plan Overview
This is a plan overview for 2025 version of Standard Gold 1500 14624MS0010007.
| Insurer: | Primewell Health Services of Mississippi |
| Network Type: | POS |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 14624MS0010007 |
Cost-Sharing Overview
Standard Gold 1500 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Standard Gold 1500 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $7800 per person | $15600 per group |
| Deductible: | $1500 per person | $3000 per group |
| Coinsurance: | 25.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Standard Gold 1500 will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | $5000 per person | $15000 per group |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $1,500 |
| Copayment: | $40 |
| Coinsurance: | $2,100 |
| Limit: | $60 |
| Deductible: | $900 |
| Copayment: | $900 |
| Coinsurance: | $0 |
| Limit: | $20 |
| Deductible: | $1,500 |
| Copayment: | $300 |
| Coinsurance: | $100 |
| Limit: | $0 |
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 Standard Gold 1500?
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
Standard Gold 1500 offers the following features and referral requirements.
| Wellness Program: | Yes |
| Disease Program: | Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Weight Loss Programs |
| Notice Pregnancy: | Yes |
| 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 Standard Gold 1500 covers when you are out of the service area or out of the country.
| Out of Country Coverage: | Yes |
| Out of Country Coverage Description: | Limited to Emergency Services only. Covered as in-network. |
| Out of Service Area Coverage: | Yes |
| Out of Service Area Coverage Description: | Out-of-Network Deductible and Co-insurance |
| National Network: | No |
Additional Benefits and Cost-Sharing
Standard Gold 1500 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 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Specialist Visit Covered | $60.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | Quantitative limits depend on the type of visit. |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Hospice Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | 6.0 Months per Lifetime Subject to Care Management. |
| Routine Dental Services (Adult) Covered | Not Applicable No Charge | Not Applicable No Charge | 2.0 Visit(s) per Year Covers exam and cleaning |
| Infertility Treatment Not Covered | |||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Not Covered | |||
| Routine Eye Exam (Adult) Covered | $60.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 1.0 Visit(s) per Year An added benefit |
| Urgent Care Centers or Facilities Covered | $45.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Home Health Care Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | May be available through the Care Management Program when provided by a network provider and prior authorization is received. |
| Emergency Room Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 25.00% Coinsurance after deductible | The ER Copay is waived if the visit results in an inpatient admission. |
| Emergency Transportation/Ambulance Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 25.00% Coinsurance after deductible | Air ambulance services are covered in only specified situations. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Copays, if applicable, are per day for first three days only. |
| Inpatient Physician and Surgical Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | 30.0 Days per Benefit Period Three-day prior inpatient stay |
| Prenatal and Postnatal Care Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Minimum stay of 48 hours; no charge for professional services |
| Mental/Behavioral Health Outpatient Services Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Inpatient treatment for mental/behavioral health disorders must be Authorized |
| Substance Abuse Disorder Outpatient Services Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Inpatient treatment for substance abuse must be Authorized |
| Generic Drugs Covered | $15.00 Not Applicable | Not Applicable 100.00% | Quantity limits, authorizations and step therapy limits may apply. |
| Preferred Brand Drugs Covered | $30.00 Not Applicable | Not Applicable 100.00% | Quantity limits, authorizations and step therapy limits may apply. |
| Non-Preferred Brand Drugs Covered | $60.00 Not Applicable | Not Applicable 100.00% | Quantity limits, authorizations and step therapy limits may apply. |
| Specialty Drugs Covered | $250.00 Not Applicable | Not Applicable 100.00% | Specialty drugs may be limited to a thirty (30) day supply. Quantity limits, authorizations and step therapy limits may apply. |
| Outpatient Rehabilitation Services Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 36.0 Visit(s) per Year Benefits available for outpatient cardiac rehabilitation. |
| Habilitation Services Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 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. |
| Chiropractic Care Covered | $60.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 20.0 Visit(s) per Year Must be medically necessary. A treatment plan outlining goals of therapy, mode of therapy and duration of therapy must be submitted to Company by the provider prior to the initiation of treatment. The 20 visit limit is combined for chiropractic services, occupational therapy, and physical therapy. |
| Durable Medical Equipment Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Various limitations apply |
| Hearing Aids Not Covered | |||
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Preventive Care/Screening/Immunization Covered | Not Applicable 0.00% | Not Applicable 50.00% | Covered services must be included in Grade A and B Recommendations of the USPSTF and include all other preventive health services required by PPACA. |
| Routine Foot Care Covered | Not Applicable 0.00% | Not Applicable 50.00% | 1.0 Visit(s) per Year Requires a Diabetes diagnosis. |
| Acupuncture Not Covered | |||
| Weight Loss Programs Covered | Not Applicable 0.00% | Not Applicable 50.00% | Non-Vantage Weight Loss programs are excluded. Vantage Weight Loss programs are covered as part of the Vantage Wellness Program. |
| Routine Eye Exam for Children Covered | $60.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 1.0 Visit(s) per Year |
| Eye Glasses for Children Covered | Not Applicable 50.00% | Not Applicable 50.00% Coinsurance after deductible | 1.0 Item(s) per Benefit Period |
| Dental Check-Up for Children Covered | No Charge Not Applicable | Not Applicable No Charge | 2.0 Visit(s) per Year |
| Rehabilitative Speech Therapy Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 20.0 Visit(s) per Year Not covered for learning disabilities and development problems. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 20.0 Visit(s) per Year The 20 visit limit is combined for chiropractic services, occupational therapy, and physical therapy. |
| Well Baby Visits and Care Covered | Not Applicable 0.00% | Not Applicable 50.00% | |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Lab services in the Emergency Room are subject to the deductible, if applicable. |
| X-rays and Diagnostic Imaging Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Basic Dental Care – Child Covered | Not Applicable 50.00% | Not Applicable 50.00% | |
| Orthodontia – Child Covered | Not Applicable 50.00% | Not Applicable 50.00% | Medically Necessary orthodontia only. |
| Major Dental Care – Child Covered | Not Applicable 50.00% | Not Applicable 50.00% | |
| Basic Dental Care – Adult Covered | Not Applicable No Charge | Not Applicable No Charge | An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care. |
| Orthodontia – Adult Not Covered | |||
| Major Dental Care – Adult Covered | Not Applicable No Charge | Not Applicable No Charge | An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care. |
| Abortion for Which Public Funding is Prohibited Not Covered | |||
| Transplant Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | Non-EHB and out-of-network transplant services not covered |
| Accidental Dental Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Dialysis Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Allergy Testing Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Chemotherapy Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Radiation Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Must be medically necessary. Company may require a treatment plan, outlining the goals of therapy, mode of therapy, and duration of therapy, to be submitted by the provider prior to the initiation of treatment. |
| Diabetes Education Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | |
| Prosthetic Devices Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Various limitations apply as stated in the Benchmark plan. |
| Infusion Therapy Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Medical necessity documentation and a treatment plan must be submitted to and approved by the Company prior to the commencement of treatment. Prior authorization is required. |
| Nutritional Counseling Covered | $30.00 Not Applicable | Not Applicable 50.00% Coinsurance after deductible | 4.0 Visit(s) per Year Coverage only for diabetes education. |
| Reconstructive Surgery Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Plan only outlines benefits for breast reconstruction. Must be medically necessary and related to mastectomy. |
| Gender Affirming Care Not Covered |
Free Preventive Services
There is no copayment or coinsurance for any of the following Standard Gold 1500 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 All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
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
Preventive Care Benefits for Women
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
Preventive Care Benefits for Children
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 Standard Gold 1500 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 Standard Gold 1500?
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