Blue Portfolio HSA Bronze - Neighborhood Network - 53901AZ1420069 Health Insurance Plan

Blue Cross and Blue Shield of Arizona, Inc. health insurance plan with the Plan ID 53901AZ1420069. The plan is called Blue Portfolio HSA Bronze - Neighborhood Network.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.60% (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 35.40% 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 53901AZ1420069
Health Insurance Plan Year 2022
State Arizona
Health Insurance Issuer Blue Cross and Blue Shield of Arizona, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 53901AZ1420069-00
Provider Network(s) ['AZN002']
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 Arizona 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 - 53901AZ1420069-00

Standard On Exchange Plan - 53901AZ1420069-01

Open to Indians below 300% FPL - 53901AZ1420069-02

Open to Indians above 300% FPL - 53901AZ1420069-03

Last Plan Update Date Tue, 08 Mar 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Blue Portfolio HSA Bronze (Free Preventive Care) Health Insurance Plan Variant 53901AZ1420069-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.6459965
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2022
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze Off Exchange Plan
Dental Only Plan No
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID AZF008
Formulary URL URL
HIOS Product ID 53901AZ142
Import Date 3/8/2022 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? Yes
Issuer ID 53901
Issuer Marketplace Marketing Name Blue Cross Blue Shield of Arizona
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Expanded Bronze
Multiple In Network Tiers No
National Network No
Network ID AZN002
Out of Country Coverage Yes
Out of Country Coverage Description Emergencies Only. Authorization required for non-emergent services.
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergencies, Urgent Care and Authorized Follow-up Care. Urgent Care and Authorized Follow-up Care covered only through contracted providers.
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan ID (Standard Component ID with Variant) 53901AZ1420069-00
Plan Level Exclusions Non-covered services and any services related to or associated with non-covered services, non-medically necessary services, and all other benefit specific and general exclusions and limitations listed in the benefit book. This exclusion does not apply to services required by federal or state law to be covered.
Plan Marketing Name Blue Portfolio HSA Bronze - Neighborhood Network
Plan Type HMO
Plan Variant Marketing Name Blue Portfolio HSA Bronze (Free Preventive Care)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $7,000
SBC Scenario, Having a Baby, Limit $50
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $5,400
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
Service Area ID AZS009
Source Name HIOS
Specialist Requiring a Referral You must select a network PCP and notify BCBSAZ of your selection. PCP referral required for all Specialists except OB/GYN, Chiropractors, Outpatient Behavioral Health providers, Physical Therapy, Occupational Therapy, Speech Therapy, Cognitive Therapy (PT, OT, ST, CT) and Cardiac and Pulmonary Rehabilitative and Habilitative Services, Pediatric Dental and Vision services, Telehealth and Urgent Care services, Walk-in Clinics, and Emergency services.
Plan ID 53901AZ1420069
State Code AZ
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 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $14000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,000
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Individual Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $14000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Blue Portfolio HSA Bronze - Neighborhood Network Health Insurance Plan, 53901AZ1420069

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

Frequently Asked Questions(FAQ) about Blue Portfolio HSA Bronze - Neighborhood Network, 53901AZ1420069 Health Insurance Plan, 53901AZ1420069

  • Does Blue Portfolio HSA Bronze - Neighborhood Network Health Insurance Plan, 53901AZ1420069 support Mail Ordering?

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

  • Does (53901AZ1420069) Health Insurance Plan, Variant (53901AZ1420069-00) have Out Of Country Coverage?

    Yes. Details: Emergencies Only. Authorization required for non-emergent services.

    Does (53901AZ1420069) Health Insurance Plan, Variant (53901AZ1420069-00) have Out of Service Area Coverage?

    Yes. Details: Emergencies, Urgent Care and Authorized Follow-up Care. Urgent Care and Authorized Follow-up Care covered only through contracted providers.

 

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