Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH - 57601NH0350026 Health Insurance Plan

Anthem Health Plans of NH(Anthem BCBS) health insurance plan with the Plan ID 57601NH0350026. The plan is called Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.95% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.05% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.83% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.17% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 57601NH0350026
Health Insurance Plan Year 2023
State New Hampshire
Health Insurance Issuer Anthem Health Plans of NH(Anthem BCBS)
Plan Formulary Description URL Formulary URL
Health Insurance Plan Variant 57601NH0350026-00
Provider Network(s) ['NHN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers New Hampshire All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 57601NH0350026-00

Standard On Exchange Plan - 57601NH0350026-01

Last Plan Update Date Mon, 22 May 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH Health Insurance Plan, 57601NH0350026-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited

Cost share driven by Provider setting.

YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Accidental Dental

Benefits are available for dental work that is Medically Necessary due to an accidental injury to sound natural teeth and gums when the course of treatment for the accidental injury is received or authorized within 3 months of the date of the injury. Cost share is driven by provider/setting.

YES

$60.00 Copay after deductible

45.00% Coinsurance after deductible
Acupuncture

Limit: 20.0 Visit(s) per Benefit Period

Limit is combined in network and out of network across all outpatient settings. Cost share driven by Provider setting.

YES

$40.00 Copay after deductible

45.00% Coinsurance after deductible
Allergy Testing
YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Bariatric Surgery

Benefits are available for bariatric surgery that is Medically Necessary for the treatment of diseases and ailments caused by or resulting from obesity or morbid obesity. Cost share driven by Provider setting.

YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Basic Dental Care - Adult
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Basic Dental Care - Child
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Chemotherapy
YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Chiropractic Care

Limit: 36.0 Visit(s) per Benefit Period

Limit is combined in network and out of network across all outpatient settings. Benefit limit does not apply to Osteopathic manipulative treatment. Cost share driven by Provider setting.

YES

$40.00 Copay after deductible

45.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Benefit Period

Limit is combined in network and out of network across all outpatient settings. Cost share driven by provider/setting.

YES

No Charge

No Charge
Diabetes Education

Cost share driven by Provider setting.

YES

$60.00 Copay after deductible

45.00% Coinsurance after deductible
Dialysis
YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Durable Medical Equipment
YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Emergency Room Services

Emergency Room copay is waived if admitted to hospital.

YES

$350.00 Copay after deductible

$350.00 Copay after deductible
Emergency Transportation/Ambulance
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

Limited reimbursement up to maximum allowable for all services. Child frames and lenses or contact lenses are covered once per benefit period. Cost share is driven by provider/setting. Limit is combined in network and out of network.

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs

Members can choose to receive a 90-day supply at retail pharmacies. When there is a copay, the copay is three times the standard retail copayment.

YES

Tier 1: $25.00 Copay after deductible

Tier 2: $35.00 Copay after deductible

50.00% Coinsurance after deductible
Habilitation Services

Limit: 60.0 Visit(s) per Benefit Period

Exclusions: The plan excludes coverage of Maintenance Therapy, defined as a treatment given when no further gains are clear or likely to occur. Maintenance therapy includes care that helps you keep your current level of function and prevents loss of that function, but does not result in any change for the better.

Limited to 60 combined visits for Physical, Occupational, and Speech Therapy benefit. Limit is combined in network and out of network across all outpatient settings. Cost share driven by Provider setting.

YES

$40.00 Copay after deductible

45.00% Coinsurance after deductible
Hearing Aids
YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Home Health Care Services

Coverage excludes Private Duty nursing services.

YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Hospice Services

Cost share driven by Provider setting.

YES

No Charge after deductible

45.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)

Cost share driven by Provider setting.

YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Infertility Treatment

Covered Services include diagnostic tests to find the cause of infertility, such as diagnostic laparoscopy, endometrial biopsy, and semen analysis. Benefits also include services to treat the underlying medical conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). Cost share driven by Provider setting.

YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Infusion Therapy
YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)

Limited to 100 days per benefit period for Inpatient Rehabilitation services. Limit applies to Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis)

YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Inpatient Physician and Surgical Services

Limited to 100 days per benefit period for Inpatient Rehabilitation services. Limit applies to Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis)

YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services

Cost share driven by Provider setting.

YES

No Charge after deductible

45.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Major Dental Care - Child
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services

Cost share driven by Provider setting.

YES

$40.00 Copay after deductible

45.00% Coinsurance after deductible
Non-Preferred Brand Drugs

Members can choose to receive a 90-day supply at retail pharmacies.

YES

Tier 1: 30.00% Coinsurance after deductible

Tier 2: 40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Nutritional Counseling

Covered under preventive guidelines and for diabetes.

YES

$40.00 Copay after deductible

40.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$40.00 Copay after deductible

45.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

Cost share driven by Provider setting.

YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Benefit Period

Limited to 60 combined visits for Physical, Occupational, and Speech Therapy benefit. Limit is combined in network and out of network across all outpatient settings. Cost share driven by Provider setting.

YES

$40.00 Copay after deductible

45.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services

Cost share driven by Provider setting.

YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Preferred Brand Drugs

Members can choose to receive a 90-day supply at retail pharmacies. When there is a copay, the copay is three times the standard retail copayment.

YES

Tier 1: $80.00 Copay after deductible

Tier 2: $90.00 Copay after deductible

50.00% Coinsurance after deductible
Prenatal and Postnatal Care

In network preventive prenatal and postnatal services are covered at 100%.

YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

No Charge

45.00% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness

PCP copay may be discounted depending upon provider selected.

YES

$40.00 Copay after deductible

45.00% Coinsurance after deductible
Private-Duty Nursing
NO
Prosthetic Devices
YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Radiation
YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Reconstructive Surgery

Cost share driven by Provider setting.

YES

25.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 60.0 Visit(s) per Benefit Period

Limited to 60 combined visits for rehabilitative Physical, Occupational, and Speech Therapy. Limit is combined in network and out of network across all outpatient settings. Cost share driven by Provider setting.

YES

$40.00 Copay after deductible

45.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Limit: 60.0 Visit(s) per Benefit Period

Limit is 60 combined visits for rehabilitative Physical, Occupational, and Speech Therapy benefit. Limit is combined in network and out of network across all outpatient settings. Cost share driven by Provider setting.

YES

$40.00 Copay after deductible

45.00% Coinsurance after deductible
Routine Dental Services (Adult)
YES

No Charge

No Charge
Routine Eye Exam (Adult)

Limit: 1.0 Visit(s) per Benefit Period

A limited reimbursement of $30 applies to Routine Eye Exams for Adults out of network. Limit is combined in network and out of network.

YES

$20.00

100.00%
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Benefit Period

Limited reimbursement up to maximum allowable for all services. Eye exams are covered once per benefit period.? Limit is combined in network and out of network.

YES

No Charge

100.00%
Routine Foot Care

Exclusions: The following services are excluded from routine foot care. Cutting or removing corns and calluses, trimming nails, cleaning and preventive foot care including but not limited to; cleaning and soaking the feet, applying skin creams to care for skin tone and other services that are given when there is not an illness, injury or symptom involving the foot.

Covered if medically necessary for illness or injury. Cost share is driven by provider/setting.

YES

$60.00 Copay after deductible

45.00% Coinsurance after deductible
Skilled Nursing Facility

Limit: 100.0 Days per Benefit Period

Limited to 100 days per benefit period for Inpatient Rehabilitation services. Limit is combined in network and out of network.

YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Specialist Visit
YES

$60.00 Copay after deductible

45.00% Coinsurance after deductible
Specialty Drugs
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services

Cost share driven by Provider setting.

YES

$40.00 Copay after deductible

45.00% Coinsurance after deductible
Transplant

Exclusions: Meals relative to transportation and lodging are excluded in and out of network.

YES

25.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Coverage includes TMJ surgery and limited non-surgical treatment. Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.

YES

25.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Urgent Care Centers or Facilities

Costs may vary by site of service.

YES

$100.00 Copay after deductible

45.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care

Covered under preventive care.

YES

No Charge

45.00% Coinsurance after deductible
X-rays and Diagnostic Imaging

Cost share driven by Provider setting.

YES

25.00% Coinsurance after deductible

45.00% Coinsurance after deductible

Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH Health Insurance Plan Variant 57601NH0350026-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.64830992
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze Off Exchange Plan
Dental Only Plan No
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, Pregnancy
First Tier Utilization 51%
Formulary ID NHF003
Formulary URL URL
HIOS Product ID 57601NH035
HSA/HRA Employer Contribution No
Import Date 5/22/2023 20:01
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 64.95%
Issuer ID 57601
Issuer Marketplace Marketing Name Anthem Blue Cross and Blue Sheld
Market Coverage SHOP (Small Group)
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Expanded Bronze
Multiple In Network Tiers Yes
National Network Yes
Network ID NHN001
Out of Country Coverage Yes
Out of Country Coverage Description Full Access
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Standard Bluecard PPO Network
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 57601NH0350026-00
Plan Marketing Name Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH
Plan Type PPO
Plan Variant Marketing Name Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,900
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $5,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $200
SBC Scenario, Having Diabetes, Deductible $5,000
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 49%
Service Area ID NHS002
Source Name SERFF
Specialty Drug Maximum Coinsurance $650
Plan ID 57601NH0350026
State Code NH
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 25.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $10000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,000
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 25.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $10000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $5000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $5,000
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $20000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $10000 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $10,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $14900 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7450 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,450
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $14900 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $7450 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $7,450
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $29800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $14900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $14,900
Unique Plan Design Yes
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH Health Insurance Plan, 57601NH0350026

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH, 57601NH0350026 Health Insurance Plan, 57601NH0350026

  • Does Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH Health Insurance Plan, 57601NH0350026 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (57601NH0350026) Health Insurance Plan, Variant (57601NH0350026-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy

    Does (57601NH0350026) Health Insurance Plan, Variant (57601NH0350026-00) have Out Of Country Coverage?

    Yes. Details: Full Access

    Does (57601NH0350026) Health Insurance Plan, Variant (57601NH0350026-00) have Out of Service Area Coverage?

    Yes. Details: Standard Bluecard PPO Network

    Does (57601NH0350026) Health Insurance Plan, Variant (57601NH0350026-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy

    Does Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH Health Insurance Plan, Variant (57601NH0350026-00) offer Disease Management Programs for Asthma?

    Yes, the Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH Health Insurance Plan Variant 57601NH0350026-00 offers Disease Management Program for Asthma.

    Does Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH Health Insurance Plan, Variant (57601NH0350026-00) offer Disease Management Programs for Heart disease?

    Yes, the Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH Health Insurance Plan Variant 57601NH0350026-00 offers Disease Management Program for Heart disease.

    Does Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH Health Insurance Plan, Variant (57601NH0350026-00) offer Disease Management Programs for Depression?

    Yes, the Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH Health Insurance Plan Variant 57601NH0350026-00 offers Disease Management Program for Depression.

    Does Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH Health Insurance Plan, Variant (57601NH0350026-00) offer Disease Management Programs for Diabetes?

    Yes, the Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH Health Insurance Plan Variant 57601NH0350026-00 offers Disease Management Program for Diabetes.

    Does Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH Health Insurance Plan, Variant (57601NH0350026-00) offer Disease Management Programs for Pregnancy?

    Yes, the Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH Health Insurance Plan Variant 57601NH0350026-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API