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Blue TrueHealth Silver - Neighborhood Network - 53901AZ1420044 Health Insurance Plan

Blue Cross and Blue Shield of Arizona, Inc. health insurance plan with the Plan ID 53901AZ1420044. The plan is called Blue TrueHealth Silver - Neighborhood Network.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 68.66% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 31.34% of the costs of all covered benefits (according to the Issuer).

Field Data
Health Insurance Plan ID53901AZ1420044
Health Insurance Plan Year2022
StateArizona
Health Insurance IssuerBlue Cross and Blue Shield of Arizona, Inc.
Plan Formulary Description URLFormulary URL
Plan Marketing Materials URLMarketing URL
Last Plan Update DateTue, 08 Mar 2022 00:00 GMT
Last Import DateSun, 24 Sep 2023 09:34 GMT
Health Insurance Plan Variant53901AZ1420044-00
 
Available Variants of the Health Plan

53901AZ1420044-00

53901AZ1420044-01

53901AZ1420044-02

53901AZ1420044-03

53901AZ1420044-04

53901AZ1420044-05

53901AZ1420044-06

Blue TrueHealth Silver (Unlimited Free Visits with Designated PCP) Health Insurance Plan Variant 53901AZ1420044-00 Attributes

Plan Attribute Value
Begin Primary Care Cost-Sharing After Number Of Visits0
Begin Primary Care Deductible Coinsurance After Number Of Copays0
Business Year2022
Child-Only OfferingAllows Adult and Child-Only
Composite Rating OfferedNo
CSR Variation TypeStandard Silver Off Exchange Plan
Dental Only PlanNo
EHB Percent of Total Premium 1
First Tier Utilization8.50%
Formulary IDAZF004
Formulary URLURL
HIOS Product ID53901AZ142
Import Date3/8/2022 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment$0.00
Inpatient Copayment Maximum Days0
HSA EligibleNo
New/Existing PlanExisting
Notice Required for PregnancyNo
Is a Referral Required for Specialist?Yes
Issuer Actuarial Value68.66%
Issuer ID53901
Issuer Marketplace Marketing NameBlue Cross Blue Shield of Arizona
Market CoverageIndividual
Medical Drug Deductibles IntegratedYes
Medical Drug Maximum Out of Pocket IntegratedYes
Metal LevelSilver
Multiple In Network TiersYes
National NetworkNo
Network IDAZN002
Out of Country CoverageYes
Out of Country Coverage DescriptionEmergencies Only. Authorization required for non-emergent services.
Out of Service Area CoverageYes
Out of Service Area Coverage DescriptionEmergencies, Urgent Care and Authorized Follow-up Care. Urgent Care and Authorized Follow-up Care covered only through contracted providers.
Plan BrochureURL
Plan Effective Date1/1/2022
Plan ID (Standard Component ID with Variant) 53901AZ1420044-00
Plan Level ExclusionsNon-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 NameBlue TrueHealth Silver - Neighborhood Network
Plan TypeHMO
Plan Variant Marketing NameBlue TrueHealth Silver (Unlimited Free Visits with Designated PCP)
QHP/Non QHPBoth
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 Utilization91.50%
Service Area IDAZS008
Source NameHIOS
Specialist Requiring a ReferralYou 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 ID53901AZ1420044
State CodeAZ
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Groupper group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Personper person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, IndividualNot Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Groupper group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Personper person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, IndividualNot Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance0.00%
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 Coinsurance0.00%
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
TEHBDedOutOfNetFamilyPerGroupper group not applicable
TEHBDedOutOfNetFamilyPerPersonper person not applicable
Combined Medical and Drug EHB Deductible, Out of Network, IndividualNot 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 Groupper group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Personper person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, IndividualNot Applicable
Unique Plan DesignYes
URL for Enrollment PaymentURL
URL for Summary of Benefits & CoverageURL
Wellness Program OfferedNo

Copay & Coinsurance of Blue TrueHealth Silver - Neighborhood Network Health Insurance Plan, 53901AZ1420044

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

Frequently Asked Questions(FAQ) about Blue TrueHealth Silver - Neighborhood Network, 53901AZ1420044 Health Insurance Plan, 53901AZ1420044

Does Blue TrueHealth Silver - Neighborhood Network Health Insurance Plan, 53901AZ1420044 support Mail Ordering?

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

Does (53901AZ1420044) Health Insurance Plan, Variant (53901AZ1420044-00) have Out Of Country Coverage?

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

Does (53901AZ1420044) Health Insurance Plan, Variant (53901AZ1420044-00) 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