my Blue Access PPO Gold 0 + Adult Dental and Vision - 76168DE0700004 Health Insurance Plan

Highmark BCBSD Inc. health insurance plan with the Plan ID 76168DE0700004. The plan is called my Blue Access PPO Gold 0 + Adult Dental and Vision.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.80% (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 19.20% 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 76168DE0700004
Health Insurance Plan Year 2022
State Delaware
Health Insurance Issuer Highmark BCBSD Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 76168DE0700004-00
Provider Network(s) ['DEN001']
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 Delaware 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 - 76168DE0700004-00

Standard On Exchange Plan - 76168DE0700004-01

Open to Indians below 300% FPL - 76168DE0700004-02

Open to Indians above 300% FPL - 76168DE0700004-03

Last Plan Update Date Thu, 16 Sep 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan Variant 76168DE0700004-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.807952815
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 Gold Off Exchange Plan
Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group per group not applicable
Drug EHB Deductible, In Network (Tier 1), Family Per Person per person not applicable
Drug EHB Deductible, In Network (Tier 1), Individual $0
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Out of Network, Individual Not Applicable
Dental Only Plan No
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 0.9376
First Tier Utilization 100%
Formulary ID DEF006
Formulary URL URL
HIOS Product ID 76168DE070
Import Date 9/16/2021 20:00
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 76168
Issuer Marketplace Marketing Name Highmark Blue Cross Blue Shield Delaware
Market Coverage Individual
Medical Drug Deductibles Integrated No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 30.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Medical EHB Deductible, In Network (Tier 1), Individual $0
Medical EHB Deductible, Out of Network, Family Per Group $4000 per group
Medical EHB Deductible, Out of Network, Family Per Person $2000 per person
Medical EHB Deductible, Out of Network, Individual $2,000
Metal Level Gold
Multiple In Network Tiers No
National Network Yes
Network ID DEN001
Out of Country Coverage Yes
Out of Country Coverage Description Coverage is provided through the Blue Cross Blue Shield Global Core when a Member requires Emergency Care Services or Urgent Care Services while traveling or living outside the United States. All Emergency Care Services and Urgent Care Services are covered in accordance within the Member's Agreement.
Out of Service Area Coverage Yes
Out of Service Area Coverage Description If a member receives non-emergency medically necessary and appropriate care from an out of area Blue Card provider, benefits will be paid in accordance with the contract.  If a member receives non-emergency care from a non-Blue Card provider, services will be covered at the lower, out-of-network level and the member will be financially responsible for the difference between the plan’s payment and the full amount of the Out-of-Area provider’s charge.
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan ID (Standard Component ID with Variant) 76168DE0700004-00
Plan Marketing Name my Blue Access PPO Gold 0 + Adult Dental and Vision
Plan Type PPO
Plan Variant Marketing Name my Blue Access PPO Gold 0 + Adult Dental and Vision
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,200
SBC Scenario, Having a Baby, Copayment $1,100
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $200
SBC Scenario, Having Diabetes, Copayment $700
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $400
SBC Scenario, Treatment of a Simple Fracture, Copayment $500
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID DES001
Source Name SERFF
Specialty Drug Maximum Coinsurance 1,000
Plan ID 76168DE0700004
State Code DE
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
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 $30000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $15000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $15,000
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan, 76168DE0700004

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

Frequently Asked Questions(FAQ) about my Blue Access PPO Gold 0 + Adult Dental and Vision, 76168DE0700004 Health Insurance Plan, 76168DE0700004

  • Does my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan, 76168DE0700004 support Mail Ordering?

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

  • Does (76168DE0700004) Health Insurance Plan, Variant (76168DE0700004-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does (76168DE0700004) Health Insurance Plan, Variant (76168DE0700004-00) have Out Of Country Coverage?

    Yes. Details: Coverage is provided through the Blue Cross Blue Shield Global Core when a Member requires Emergency Care Services or Urgent Care Services while traveling or living outside the United States. All Emergency Care Services and Urgent Care Services are covered in accordance within the Member's Agreement.

    Does (76168DE0700004) Health Insurance Plan, Variant (76168DE0700004-00) have Out of Service Area Coverage?

    Yes. Details: If a member receives non-emergency medically necessary and appropriate care from an out of area Blue Card provider, benefits will be paid in accordance with the contract.  If a member receives non-emergency care from a non-Blue Card provider, services will be covered at the lower, out-of-network level and the member will be financially responsible for the difference between the plan’s payment and the full amount of the Out-of-Area provider’s charge.

    Does (76168DE0700004) Health Insurance Plan, Variant (76168DE0700004-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan, Variant (76168DE0700004-00) offer Disease Management Programs for Asthma?

    Yes, the my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan Variant 76168DE0700004-00 offers Disease Management Program for Asthma.

    Does my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan, Variant (76168DE0700004-00) offer Disease Management Programs for Heart disease?

    Yes, the my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan Variant 76168DE0700004-00 offers Disease Management Program for Heart disease.

    Does my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan, Variant (76168DE0700004-00) offer Disease Management Programs for Depression?

    Yes, the my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan Variant 76168DE0700004-00 offers Disease Management Program for Depression.

    Does my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan, Variant (76168DE0700004-00) offer Disease Management Programs for Diabetes?

    Yes, the my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan Variant 76168DE0700004-00 offers Disease Management Program for Diabetes.

    Does my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan, Variant (76168DE0700004-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan Variant 76168DE0700004-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan, Variant (76168DE0700004-00) offer Disease Management Programs for Low back pain?

    Yes, the my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan Variant 76168DE0700004-00 offers Disease Management Program for Low back pain.

    Does my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan, Variant (76168DE0700004-00) offer Disease Management Programs for Pregnancy?

    Yes, the my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan Variant 76168DE0700004-00 offers Disease Management Program for Pregnancy.

    Does my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan, Variant (76168DE0700004-00) offer Disease Management Programs for Weight loss programs?

    Yes, the my Blue Access PPO Gold 0 + Adult Dental and Vision Health Insurance Plan Variant 76168DE0700004-00 offers Disease Management Program for Weight loss programs.

 

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