Security Health Plan of Wisconsin, Inc.

SimplyOne $6,200 HDHP

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $6,200.00
  • Family: $12,400
  • Per Person: $6,200
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $7,000.00
  • Family: $14,000
  • Per Person: $7,000

Office Visit

Primary Doctor
  • CoPay: No Charge after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered
Specialist
  • CoPay: $75.00 Copay after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $80.00 Copay after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.
Non Preferred Brand Drugs
  • CoPay: $150.00 Copay after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.
Generic Drugs
  • CoPay: $25.00 Copay after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.
Specialty Drugs
  • CoPay: No Charge after deductible
  • CoInsurance: 45.00% Coinsurance after deductible
  • Covered: Covered
  • Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.

Inpatient Coverage

Hospital Services
  • CoPay: $250.00 Copay per Day after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered
Inpatient Services
  • CoPay: No Charge after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: $450.00 Copay after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: Limitations include: care that can safely be postponed until the member returns to the service area, follow-up care received from a non-network provider unless prior authorized by Security Health Plan and take-home drugs and supplies dispensed by a hospital at the time of hospital discharge for use at home.
Urgent Care Facility
  • CoPay: $75.00 Copay after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: Limitations include: care that can safely be postponed until the member returns to the service area, follow-up care received from a non-network provider unless prior authorized by Security Health Plan and take-home drugs and supplies dispensed by a hospital at the time of hospital discharge for use at home.

Maternity

Labor and Delivery Hospital Stay
  • CoPay: No Charge after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: Limitations include: prenatal cradle (maternity belt), home delivery and home visits, services performed by a licensed midwife or certified professional midwife, services to determine gender, abortion procedures to end a pregnancy except as specifically stated above.
Pre and Postnatal Office Visit
  • CoPay: No Charge after deductible
  • CoInsurance: No Charge after deductible
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: No Charge
  • CoInsurance: No Charge
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per Year

Major Dental Care

Routine Dental Checkups for Children
  • Covered: Not Covered
Routine Dental Checkups for Adults
  • Covered: Not Covered
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© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN38166WI0270005ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN38166WI0270005ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN38166WI0270005ACA1