University of Michigan Health PHP Exclusive Gold 1400

60829MI0190050
Gold
HMO

University of Michigan Health PHP Exclusive Gold 1400 is a Gold HMO plan by Physicians Health Plan.

IMPORTANT: You are viewing the 2023 version of University of Michigan Health PHP Exclusive Gold 1400 60829MI0190050. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

University of Michigan Health PHP Exclusive Gold 1400 is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of University of Michigan Health PHP Exclusive Gold 1400 60829MI0190050.
Insurer: Physicians Health Plan
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 60829MI0190050

Cost-Sharing Overview

University of Michigan Health PHP Exclusive Gold 1400 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 University of Michigan Health PHP Exclusive Gold 1400?

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

University of Michigan Health PHP Exclusive Gold 1400 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 University of Michigan Health PHP Exclusive Gold 1400 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

University of Michigan Health PHP Exclusive Gold 1400 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
$50.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
20.00% 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
20.00% 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
20.00% 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
20.00% 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
$60.00 $60.00 Urgent care center visits are always covered at network benefit level.
Home Health Care Services
Covered
20.00% Coinsurance after deductible 100.00% Prior approval required.
Emergency Room Services
Covered
20.00% Coinsurance after deductible 20.00% Coinsurance after deductible Emergency Department visits are always covered at network benefit level. Approval required if admitted as inpatient.
Emergency Transportation/Ambulance
Covered
20.00% Coinsurance after deductible 20.00% Coinsurance after deductible Emergency ambulance services are always covered at network benefit level.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
20.00% Coinsurance after deductible 100.00% Prior approval required.
Inpatient Physician and Surgical Services
Covered
20.00% 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
20.00% Coinsurance after deductible 100.00%45 Days per Year Custodial care, private duty nursing Prior approval required.
Prenatal and Postnatal Care
Covered
20.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
20.00% 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
20.00% 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
20.00% Coinsurance after deductible 100.00% Prior approval required.
Generic Drugs
Covered
$40.00 100.00%
Preferred Brand Drugs
Covered
$65.00 100.00%
Non-Preferred Brand Drugs
Covered
$125.00 100.00%
Specialty Drugs
Covered
30.00% 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
$50.00 100.00%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
$50.00 100.00%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
20.00% 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
20.00% Coinsurance after deductible 100.00%1 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$50.00 100.00%30 Visit(s) per Year Prior approval required.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$50.00 100.00%30 Visit(s) per Year
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
20.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
20.00% 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
20.00% Coinsurance after deductible 100.00% Must be done at Designated Facility. Prior approval required.
Accidental Dental
Covered
$50.00 100.00% Approval required prior to follow-up care
Dialysis
Covered
20.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
50.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
20.00% Coinsurance after deductible 100.00%
Radiation
Covered
20.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
20.00% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
50.00% 100.00% Prior approval required if cost over $1,000.
Infusion Therapy
Covered
20.00% 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
20.00% Coinsurance after deductible 100.00% Prior approval required.
Reconstructive Surgery
Covered
20.00% Coinsurance after deductible 100.00% Prior approval required
Gender Affirming Care
Covered
20.00% Coinsurance after deductible 100.00% Prior approval required
Autism Spectrum Disorders
Covered
20.00% Coinsurance after deductible 100.00% Prior approval required
Clinical Trials
Covered
20.00% 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
20.00% Coinsurance after deductible 100.00% Prior approval required.
Substance Use Disorders – Intermediate
Covered
20.00% Coinsurance after deductible 100.00% Prior approval required.
Telemedicine Services
Covered
$30.00 100.00%
Non-Preferred Specialty Drugs
Covered
30.00% 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.
Preferred Generic Drugs
Covered
$5.00 100.00% 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 University of Michigan Health PHP Exclusive Gold 1400 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 University of Michigan Health PHP Exclusive Gold 1400 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 University of Michigan Health PHP Exclusive Gold 1400?

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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