Blue PPO Silver - Statewide PPO Network - 53901AZ1490002 Health Insurance Plan

Blue Cross and Blue Shield of Arizona, Inc. health insurance plan with the Plan ID 53901AZ1490002. The plan is called Blue PPO Silver - Statewide PPO Network.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.94% (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 28.06% 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 53901AZ1490002
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 53901AZ1490002-00
Provider Network(s) ['AZN003']
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 - 53901AZ1490002-00

Standard On Exchange Plan - 53901AZ1490002-01

Open to Indians below 300% FPL - 53901AZ1490002-02

Open to Indians above 300% FPL - 53901AZ1490002-03

73% AV Silver Plan - 53901AZ1490002-04

87% AV Silver Plan - 53901AZ1490002-05

94% AV Silver Plan - 53901AZ1490002-06

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

Blue PPO Silver (2 Free Primary Care Visits In-Network) Health Insurance Plan Variant 53901AZ1490002-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.719413058
Begin Primary Care Cost-Sharing After Number Of Visits 2
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 Silver Off Exchange Plan
Dental Only Plan No
EHB Percent of Total Premium 1
First Tier Utilization 8.50%
Formulary ID AZF010
Formulary URL URL
HIOS Product ID 53901AZ149
Import Date 3/8/2022 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
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 Silver
Multiple In Network Tiers Yes
National Network Yes
Network ID AZN003
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 All Benefits
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan ID (Standard Component ID with Variant) 53901AZ1490002-00
Plan Marketing Name Blue PPO Silver - Statewide PPO Network
Plan Type PPO
Plan Variant Marketing Name Blue PPO Silver (2 Free Primary Care Visits In-Network)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,370
SBC Scenario, Having a Baby, Copayment $80
SBC Scenario, Having a Baby, Deductible $3,100
SBC Scenario, Having a Baby, Limit $50
SBC Scenario, Having Diabetes, Coinsurance $840
SBC Scenario, Having Diabetes, Copayment $330
SBC Scenario, Having Diabetes, Deductible $50
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $150
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,300
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 91.50%
Service Area ID AZS013
Source Name HIOS
Plan ID 53901AZ1490002
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 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $6200 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $3100 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $3,100
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $6200 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $3100 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $3,100
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $18000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $9000 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $9,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $8,700
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $36000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $18000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $18,000
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Blue PPO Silver - Statewide PPO Network Health Insurance Plan, 53901AZ1490002

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

Frequently Asked Questions(FAQ) about Blue PPO Silver - Statewide PPO Network, 53901AZ1490002 Health Insurance Plan, 53901AZ1490002

  • Does Blue PPO Silver - Statewide PPO Network Health Insurance Plan, 53901AZ1490002 support Mail Ordering?

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

  • Does (53901AZ1490002) Health Insurance Plan, Variant (53901AZ1490002-00) have Out Of Country Coverage?

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

    Does (53901AZ1490002) Health Insurance Plan, Variant (53901AZ1490002-00) have Out of Service Area Coverage?

    Yes. Details: All Benefits

 

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