Bronze HSA 6750 - 22013UT2650007 Health Insurance Plan

Regence BlueCross BlueShield of Utah health insurance plan with the Plan ID 22013UT2650007. The plan is called Bronze HSA 6750.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.16% (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 36.84% 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 22013UT2650007
Health Insurance Plan Year 2023
State Utah
Health Insurance Issuer Regence BlueCross BlueShield of Utah
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 22013UT2650007-00
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 - 22013UT2650007-00

Standard On Exchange Plan - 22013UT2650007-01

Open to Indians below 300% FPL - 22013UT2650007-02

Open to Indians above 300% FPL - 22013UT2650007-03

Last Plan Update Date Wed, 17 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Bronze HSA 6750 Health Insurance Plan, 22013UT2650007-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
NO
Acupuncture
NO
Allergy Testing
YES

50.00% Coinsurance after deductible

100.00%
Autism Spectrum Disorders
YES

50.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

50.00% Coinsurance after deductible

100.00%
Chiropractic Care
NO
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

50.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 2.0 Exam(s) per Year

YES

No Charge

100.00%
Diabetes Care Management
YES

50.00% Coinsurance after deductible

100.00%
Diabetes Education
YES

No Charge

100.00%
Dialysis
YES

50.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home.

YES

50.00% Coinsurance after deductible

100.00%
Emergency Room Services

Out of service area coverage is available.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Out of service area coverage is available.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
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

No Charge

100.00%
Gender Affirming Care
YES

50.00% Coinsurance after deductible

100.00%
Generic Drugs

insulin limit of? $27 per 30 days? $81 for 90 day supply

YES

20.00% Coinsurance after deductible

100.00%
Habilitation Services

Limit: 20.0 Visit(s) per Benefit Period

Habilitation services limited to 30 inpatient days per year and 20 outpatient visits per year.

YES

50.00% Coinsurance after deductible

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 30.0 Visit(s) per Benefit Period

YES

50.00% Coinsurance after deductible

100.00%
Hospice Services

Limit: 6.0 Months per 3 Years

YES

50.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

50.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

50.00% Coinsurance after deductible

100.00%
Inherited Metabolic Disorder - PKU
YES

50.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

50.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

50.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

YES

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

YES

50.00% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs

insulin limit of? $27 per 30 days? $81 for 90 day supply

YES

50.00% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

50.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

50.00% Coinsurance after deductible

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

50.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Benefit Period

Combined rehabilitative limit for outpatient physical, occupational and speech therapies. 20 outpatient visits per year. Visit limit does not apply to Mental Health/Substance Abuse.

YES

50.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

insulin limit of? $27 per 30 days? $81 for 90 day supply

YES

40.00% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care
YES

50.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

50.00% Coinsurance after deductible

100.00%
Private-Duty Nursing
NO
Prosthetic Devices

Limited covered services.

YES

50.00% Coinsurance after deductible

100.00%
Radiation
YES

50.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Covers mastectomy in the treatment of cancer and reconstructive surgery after a mastectomy.

YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Benefit Period

Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. Visit limit does not apply to Mental Health/Substance Abuse.

YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Benefit Period

Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. Visit limit does not apply to Mental Health/Substance Abuse.

YES

50.00% Coinsurance after deductible

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

No Charge

100.00%
Routine Foot Care

Covered when medically necessary.

YES

50.00% Coinsurance after deductible

100.00%
Skilled Nursing Facility

Limit: 30.0 Visit(s) per Benefit Period

30 days per year for Inpatient Rehabilitation and Skilled Nursing Facility combined

YES

50.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

50.00% Coinsurance after deductible

100.00%
Specialty Drugs

First fill allowed at a retail pharmacy. Insulin limit of $27 per 30 days, $81 for 90 day-supply

YES

40.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services

Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

YES

50.00% Coinsurance after deductible

100.00%
Transplant
YES

50.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities

Out of service area coverage is available.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

50.00% Coinsurance after deductible

100.00%

Bronze HSA 6750 Health Insurance Plan Variant 22013UT2650007-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.63158926
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 Standard Bronze Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID UTF005
Formulary URL URL
HIOS Product ID 22013UT265
Import Date 8/17/2022 20:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 22013
Issuer Marketplace Marketing Name Regence BlueCross BlueShield of Utah
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 1/1/2023
Plan ID (Standard Component ID with Variant) 22013UT2650007-00
Plan Marketing Name Bronze HSA 6750
Plan Type EPO
Plan Variant Marketing Name Bronze HSA 6750
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $750
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $6,750
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 22013UT2650007
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 $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, 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 $15000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,500
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 HSA 6750 Health Insurance Plan, 22013UT2650007

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

Frequently Asked Questions(FAQ) about Bronze HSA 6750, 22013UT2650007 Health Insurance Plan, 22013UT2650007

  • Does Bronze HSA 6750 Health Insurance Plan, 22013UT2650007 support Mail Ordering?

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

  • Does (22013UT2650007) Health Insurance Plan, Variant (22013UT2650007-00) have Out Of Country Coverage?

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

    Does (22013UT2650007) Health Insurance Plan, Variant (22013UT2650007-00) 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