my Blue Access PPO Standard Silver 5800 - 76168DE0760002 Health Insurance Plan

Highmark BCBSD Inc. health insurance plan with the Plan ID 76168DE0760002. The plan is called my Blue Access PPO Standard Silver 5800.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.47% (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 29.53% 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 76168DE0760002
Health Insurance Plan Year 2023
State Delaware
Health Insurance Issuer Highmark BCBSD Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 76168DE0760002-00
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 - 76168DE0760002-00

Standard On Exchange Plan - 76168DE0760002-01

Open to Indians below 300% FPL - 76168DE0760002-02

Open to Indians above 300% FPL - 76168DE0760002-03

73% AV Silver Plan - 76168DE0760002-04

87% AV Silver Plan - 76168DE0760002-05

94% AV Silver Plan - 76168DE0760002-06

Last Plan Update Date Thu, 15 Sep 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of my Blue Access PPO Standard Silver 5800 Health Insurance Plan, 76168DE0760002-00

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

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Acupuncture
NO
Allergy Testing
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Bariatric Surgery
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

50.00%

100.00%
Chemotherapy
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chiropractic Care

Limit: 30.0 Visit(s) per Benefit Period

YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Clinical Trials
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 1.0 Exam(s) per 6 Months

YES

No Charge

100.00%
Diabetes Care Management
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Diabetes Education
YES

No Charge

100.00%
Dialysis
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Durable Medical Equipment
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Room Services
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs
YES

$20.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Benefit Period

In parity with and comparable to outpatient rehabilitation services; 30 visits combined PT/OT and 30 visits speech therapy.

YES

$17.00

25.00% Coinsurance after deductible
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

Limited to one hearing aid, per person, per ear, every three years for members under age 24

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Home Health Care Services

Limit: 100.0 Visit(s) per Benefit Period

Aggregate with Visiting Nurse

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Hospice Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)

Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance abuse.

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Infertility Treatment
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Infusion Therapy
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inherited Metabolic Disorder - PKU
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services

Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance abuse.

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

50.00%

100.00%
Mental/Behavioral Health Inpatient Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
YES

$40.00

50.00% Coinsurance after deductible
Non-Preferred Brand Drugs
YES

$80.00 Copay after deductible

100.00%
Nutritional Counseling
YES

No Charge

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
YES

50.00%

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$40.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Benefit Period

YES

$17.00

25.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preferred Brand Drugs
YES

$40.00

100.00%
Prenatal and Postnatal Care
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

No Charge

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

$40.00

50.00% Coinsurance after deductible
Private-Duty Nursing

Limit: 240.0 Hours per Benefit Period

Exclusions: Outpatient not covered

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Prosthetic Devices
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Radiation
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Reconstructive Surgery
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Benefit Period

Limited to a combined total of thirty (30) Outpatient Visits for rehabilitative purposes per Benefit Period and a combined total of thirty (30) Outpatient Visits for habilitative purposes per Benefit Period. This limit does not apply when therapy services are prescribed for the treatment of Mental Illness or Substance Abuse.

YES

$17.00

25.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Benefit Period

Limited to thirty (30) Outpatient Visits for rehabilitative purposes per Benefit Period and thirty (30) Outpatient Visits for habilitative purposes per Benefit Period. This limit does not apply when therapy services are prescribed for the treatment of Mental Illness or Substance Abuse.

YES

$40.00

25.00% Coinsurance after deductible
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
NO
Skilled Nursing Facility

Limit: 120.0 Days per Benefit Period

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Specialist Visit
YES

$80.00

50.00% Coinsurance after deductible
Specialty Drugs
YES

$125.00 Copay after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
YES

$40.00

50.00% Coinsurance after deductible
Transplant
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders

Exclusions: Limited to Services to Determine Initial Diagnosis. Exclude Treatment Coverage when TMJ or Related Diagnosis Is only Reason for Treatment

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Urgent Care Centers or Facilities

The copayment, if any, does not apply to urgent care services prescribed for the treatment of mental illness or substance abuse.

YES

$60.00

$60.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging

Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance abuse.

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible

my Blue Access PPO Standard Silver 5800 Health Insurance Plan Variant 76168DE0760002-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.704703186
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 Silver Off Exchange Plan
Dental Only Plan No
Design Type Design 2
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 1
First Tier Utilization 100%
Formulary ID DEF011
Formulary URL URL
HIOS Product ID 76168DE076
Import Date 9/15/2022 20:01
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 Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
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 1/1/2023
Plan ID (Standard Component ID with Variant) 76168DE0760002-00
Plan Marketing Name my Blue Access PPO Standard Silver 5800
Plan Type PPO
Plan Variant Marketing Name my Blue Access PPO Standard Silver 5800
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,700
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $5,800
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,100
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $400
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,100
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID DES001
Source Name SERFF
Plan ID 76168DE0760002
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
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 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $11600 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5800 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,800
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $23200 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $11600 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $11,600
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $17800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,900
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $35600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $17800 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $17,800
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 Standard Silver 5800 Health Insurance Plan, 76168DE0760002

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

Frequently Asked Questions(FAQ) about my Blue Access PPO Standard Silver 5800, 76168DE0760002 Health Insurance Plan, 76168DE0760002

  • Does my Blue Access PPO Standard Silver 5800 Health Insurance Plan, 76168DE0760002 support Mail Ordering?

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

  • Does (76168DE0760002) Health Insurance Plan, Variant (76168DE0760002-00) 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 (76168DE0760002) Health Insurance Plan, Variant (76168DE0760002-00) 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 (76168DE0760002) Health Insurance Plan, Variant (76168DE0760002-00) 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 (76168DE0760002) Health Insurance Plan, Variant (76168DE0760002-00) 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 Standard Silver 5800 Health Insurance Plan, Variant (76168DE0760002-00) offer Disease Management Programs for Asthma?

    Yes, the my Blue Access PPO Standard Silver 5800 Health Insurance Plan Variant 76168DE0760002-00 offers Disease Management Program for Asthma.

    Does my Blue Access PPO Standard Silver 5800 Health Insurance Plan, Variant (76168DE0760002-00) offer Disease Management Programs for Heart disease?

    Yes, the my Blue Access PPO Standard Silver 5800 Health Insurance Plan Variant 76168DE0760002-00 offers Disease Management Program for Heart disease.

    Does my Blue Access PPO Standard Silver 5800 Health Insurance Plan, Variant (76168DE0760002-00) offer Disease Management Programs for Depression?

    Yes, the my Blue Access PPO Standard Silver 5800 Health Insurance Plan Variant 76168DE0760002-00 offers Disease Management Program for Depression.

    Does my Blue Access PPO Standard Silver 5800 Health Insurance Plan, Variant (76168DE0760002-00) offer Disease Management Programs for Diabetes?

    Yes, the my Blue Access PPO Standard Silver 5800 Health Insurance Plan Variant 76168DE0760002-00 offers Disease Management Program for Diabetes.

    Does my Blue Access PPO Standard Silver 5800 Health Insurance Plan, Variant (76168DE0760002-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the my Blue Access PPO Standard Silver 5800 Health Insurance Plan Variant 76168DE0760002-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does my Blue Access PPO Standard Silver 5800 Health Insurance Plan, Variant (76168DE0760002-00) offer Disease Management Programs for Low back pain?

    Yes, the my Blue Access PPO Standard Silver 5800 Health Insurance Plan Variant 76168DE0760002-00 offers Disease Management Program for Low back pain.

    Does my Blue Access PPO Standard Silver 5800 Health Insurance Plan, Variant (76168DE0760002-00) offer Disease Management Programs for Pregnancy?

    Yes, the my Blue Access PPO Standard Silver 5800 Health Insurance Plan Variant 76168DE0760002-00 offers Disease Management Program for Pregnancy.

    Does my Blue Access PPO Standard Silver 5800 Health Insurance Plan, Variant (76168DE0760002-00) offer Disease Management Programs for Weight loss programs?

    Yes, the my Blue Access PPO Standard Silver 5800 Health Insurance Plan Variant 76168DE0760002-00 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