| Field | Data |
|---|---|
| Health Insurance Plan ID | 53901AZ1420043 |
| 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 |
| Last Plan Update Date | Tue, 08 Mar 2022 00:00 GMT |
| Last Import Date | Sun, 24 Sep 2023 09:34 GMT |
| Health Insurance Plan Variant | 53901AZ1420043-00 |
| Available Variants of the Health Plan | |
| Plan Attribute | Value |
|---|---|
| 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 Silver Off Exchange Plan |
| Dental Only Plan | No |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 8.50% |
| Formulary ID | AZF004 |
| 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 | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 68.66% |
| 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 | 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) | 53901AZ1420043-00 |
| 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 TrueHealth Silver - Neighborhood Network |
| Plan Type | HMO |
| Plan Variant Marketing Name | Blue TrueHealth Silver (Unlimited Free Visits with Designated PCP) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $110 |
| SBC Scenario, Having a Baby, Deductible | $6,750 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $840 |
| SBC Scenario, Having Diabetes, Deductible | $4,260 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $180 |
| 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 | AZS007 |
| 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 | 53901AZ1420043 |
| 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 | $13500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6750 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,750 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $13500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $6750 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $6,750 |
| TEHBDedOutOfNetFamilyPerGroup | per group not applicable |
| TEHBDedOutOfNetFamilyPerPerson | 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 | $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 | 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 | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue TrueHealth Silver - Neighborhood Network, 53901AZ1420043 Health Insurance Plan, 53901AZ1420043
Does Blue TrueHealth Silver - Neighborhood Network Health Insurance Plan, 53901AZ1420043 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (53901AZ1420043) Health Insurance Plan, Variant (53901AZ1420043-00) have Out Of Country Coverage?
Yes. Details: Emergencies Only. Authorization required for non-emergent services.
Does (53901AZ1420043) Health Insurance Plan, Variant (53901AZ1420043-00) 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: Sun, 24 Sep 2023 09:34 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