Bronze Essential 8000 With 4 Copay No Deductible Office Visits Legacy LHP - 77969OR5280017 Health Insurance Plan
Regence BlueCross BlueShield of Oregon health insurance plan with the Plan ID 77969OR5280017. The plan is called Bronze Essential 8000 With 4 Copay No Deductible Office Visits Legacy LHP.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 77969OR5280017 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Oregon | ||||||||||||||||||
| Health Insurance Issuer | Regence BlueCross BlueShield of Oregon | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 77969OR5280017-02 | ||||||||||||||||||
| Provider Network(s) | ['ORN002'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Apr 2024 06:19 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 77969OR5280017-00 Standard On Exchange Plan - 77969OR5280017-01 |
||||||||||||||||||
| Last Plan Update Date | Wed, 17 Aug 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Apr 2024 06:19 GMT |
Benefits of Bronze Essential 8000 With 4 Copay No Deductible Office Visits Legacy LHP Health Insurance Plan, 77969OR5280017-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | $0.00, 0.00% |
100.00% |
| Accidental Dental
|
YES | $0.00, 0.00% |
100.00% |
| Acupuncture
Limit: 12.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Allergy Testing
|
YES | $0.00, 0.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | $0.00, 0.00% |
100.00% |
| Chemotherapy
|
YES | $0.00, 0.00% |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Cosmetic Surgery
one attempt to correct a scar or defect that resulted from an accidental injury or treatment for an accidental injury or one attempt to correct a scar or defect on the head or neck that resulted from a surgery (more than one attempt is covered if medically necessary) |
YES | $0.00, 0.00% |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | $0.00, 0.00% |
100.00% |
| Dental Check-Up for Children
|
YES | $0.00, 0.00% |
100.00% |
| Diabetes Education
|
YES | $0.00, 0.00% |
100.00% |
| Dialysis
|
YES | $0.00, 0.00% |
100.00% |
| Durable Medical Equipment
Hardware to correct visual defect due to severe medical or surgical problem such as stroke, neurological disease, trauma or eye surgery other than refractive procedures limited to one pair of glasses (frames and lenses) or contact lenses per calendar year. |
YES | $0.00, 0.00% |
100.00% |
| Emergency Room Services
Out of service area coverage is available |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
Out of service area coverage is available |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year One pair of lenses and one frame per year (contacts in lieu of glasses) |
YES | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
Information about gender affirming care can be found in plan documents. |
YES | $0.00, 0.00% |
100.00% |
| Generic Drugs
Insulin: $80 max out of pocket for 30 day supply prior to deductible |
YES | $0.00, 0.00% |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Visit limit does not apply to treatment of mental health conditions. |
YES | $0.00, 0.00% |
100.00% |
| Hearing Aids
Hearing assistance coverage complies with state and federal law |
YES | $0.00, 0.00% |
100.00% |
| Home Health Care Services
|
YES | $0.00, 0.00% |
100.00% |
| Hospice Services
Respite care - max of 5 consecutive days; lifetime max of 30 days |
YES | $0.00, 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $0.00, 0.00% |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | $0.00, 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $0.00, 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $0.00, 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $0.00, 0.00% |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Non-Preferred Brand Drugs
Insulin: $80 max out of pocket for 30 day supply prior to deductible |
YES | $0.00, 0.00% |
100.00% |
| Nutritional Counseling
|
YES | $0.00, 0.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | $0.00, 0.00% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
The first 4 in-network PCP, in-network Specialists, and Urgent Care office visits combined per calendar year are not subject to the deductible. |
YES | $0.00, 0.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $0.00, 0.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Combined limit of 30 visits for OT, ST, and PT. Visit limit does not apply to treatment of mental health conditions. |
YES | $0.00, 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $0.00, 0.00% |
100.00% |
| Preferred Brand Drugs
Insulin: $80 max out of pocket for 30 day supply prior to deductible |
YES | $0.00, 0.00% |
100.00% |
| Prenatal and Postnatal Care
|
YES | $0.00, 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | $0.00, 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
The first 4 in-network PCP, in-network Specialists, and Urgent Care office visits combined per calendar year are not subject to the deductible. |
YES | $0.00, 0.00% |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | $0.00, 0.00% |
100.00% |
| Radiation
|
YES | $0.00, 0.00% |
100.00% |
| Reconstructive Surgery
|
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Limit combined with Occupational, Physical, and Speech therapy. Visit limit does not apply to Mental Health/Substance Abuse. |
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Limit combined with Occupational, Physical, and Speech therapy. Visit limit does not apply to Mental Health/Substance Abuse. |
YES | $0.00, 0.00% |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Routine Foot Care
Covered when medically necessary. |
YES | $0.00, 0.00% |
100.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | $0.00, 0.00% |
100.00% |
| Specialist Visit
The first 4 in-network PCP, in-network Specialists, and Urgent Care office visits combined per calendar year are not subject to the deductible. |
YES | $0.00, 0.00% |
100.00% |
| Specialty Drugs
Insulin: $80 max out of pocket for 30 day supply prior to deductible |
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $0.00, 0.00% |
100.00% |
| Telehealth-Primary Care Visit
|
YES | $0.00, 0.00% |
100.00% |
| Telehealth-Specialist Visit
|
YES | $0.00, 0.00% |
100.00% |
| Tier 1-Zero Cost-Share Preventive Drugs
Insulin: $80 max out of pocket for 30 day supply prior to deductible |
YES | $0.00, 0.00% |
100.00% |
| Tier 2-Preferred Generic Drugs
Insulin: $80 max out of pocket for 30 day supply prior to deductible |
YES | $0.00, 0.00% |
100.00% |
| Tier 3-Non-Preferred Generic Drugs
Insulin: $80 max out of pocket for 30 day supply prior to deductible |
YES | $0.00, 0.00% |
100.00% |
| Tier 4-Preferred Brand Drugs
Insulin: $80 max out of pocket for 30 day supply prior to deductible |
YES | $0.00, 0.00% |
100.00% |
| Tier 5-Non-Preferred Brand Drugs
Insulin: $80 max out of pocket for 30 day supply prior to deductible |
YES | $0.00, 0.00% |
100.00% |
| Tier 6-Preferred Specialty Drugs
Insulin: $80 max out of pocket for 30 day supply prior to deductible |
YES | $0.00, 0.00% |
100.00% |
| Tier 7-Non-Preferred Specialty Drugs
Insulin: $80 max out of pocket for 30 day supply prior to deductible |
YES | $0.00, 0.00% |
100.00% |
| Transplant
|
YES | $0.00, 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
Out of service area coverage is available. The first 4 in-network PCP, in-network Specialists, and Urgent Care office visits combined per calendar year are not subject to the deductible. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | $0.00, 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $0.00, 0.00% |
100.00% |
Bronze Essential 8000 With 4 Copay No Deductible Office Visits Legacy LHP Health Insurance Plan Variant 77969OR5280017-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1 |
| 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 | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 0.996 |
| First Tier Utilization | 100% |
| Formulary ID | ORF012 |
| Formulary URL | URL |
| HIOS Product ID | 77969OR528 |
| Import Date | 8/17/2022 20:01 |
| 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? | No |
| Issuer ID | 77969 |
| Issuer Marketplace Marketing Name | Regence BlueCross BlueShield of Oregon |
| 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 | ORN002 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 77969OR5280017-02 |
| Plan Marketing Name | Bronze Essential 8000 With 4 Copay No Deductible Office Visits Legacy LHP |
| Plan Type | EPO |
| Plan Variant Marketing Name | Bronze Essential 8000 With 4 Copay No Deductible Office Visits Legacy LHP |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ORS002 |
| Source Name | SERFF |
| Plan ID | 77969OR5280017 |
| State Code | OR |
| 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 | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| 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 Bronze Essential 8000 With 4 Copay No Deductible Office Visits Legacy LHP Health Insurance Plan, 77969OR5280017
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Bronze Essential 8000 With 4 Copay No Deductible Office Visits Legacy LHP, 77969OR5280017 Health Insurance Plan, 77969OR5280017
-
Does Bronze Essential 8000 With 4 Copay No Deductible Office Visits Legacy LHP Health Insurance Plan, 77969OR5280017 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (77969OR5280017) Health Insurance Plan, Variant (77969OR5280017-02) have Out Of Country Coverage?
Does (77969OR5280017) Health Insurance Plan, Variant (77969OR5280017-02) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 16 Apr 2024 06:19 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