Bronze HDHP 6500 - 34541UT0280003 Health Insurance Plan

BridgeSpan Health Company health insurance plan with the Plan ID 34541UT0280003. The plan is called Bronze HDHP 6500.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.66% (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 35.34% 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 34541UT0280003
Health Insurance Plan Year 2022
State Utah
Health Insurance Issuer BridgeSpan Health Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 34541UT0280003-00
Provider Network(s) ['UTN001']
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 Utah 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 - 34541UT0280003-00

Standard On Exchange Plan - 34541UT0280003-01

Open to Indians below 300% FPL - 34541UT0280003-02

Open to Indians above 300% FPL - 34541UT0280003-03

Last Plan Update Date Thu, 02 Dec 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Bronze HDHP 6500 Health Insurance Plan Variant 34541UT0280003-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.646613601
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 UTF002
Formulary URL URL
HIOS Product ID 34541UT028
Import Date 12/2/2021 20:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 34541
Issuer Marketplace Marketing Name BridgeSpan Health Company
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 UTN001
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan ID (Standard Component ID with Variant) 34541UT0280003-00
Plan Marketing Name Bronze HDHP 6500
Plan Type HMO
Plan Variant Marketing Name Bronze HDHP 6500
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $600
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $6,500
SBC Scenario, Having a Baby, Limit $61
SBC Scenario, Having Diabetes, Coinsurance $1,250
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $2,029
SBC Scenario, Having Diabetes, Limit $178
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 UTS001
Source Name SERFF
Plan ID 34541UT0280003
State Code UT
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 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $13000 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 $6,500
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 Bronze HDHP 6500 Health Insurance Plan, 34541UT0280003

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

Frequently Asked Questions(FAQ) about Bronze HDHP 6500, 34541UT0280003 Health Insurance Plan, 34541UT0280003

  • Does Bronze HDHP 6500 Health Insurance Plan, 34541UT0280003 support Mail Ordering?

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

  • Does (34541UT0280003) Health Insurance Plan, Variant (34541UT0280003-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (34541UT0280003) Health Insurance Plan, Variant (34541UT0280003-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

 

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