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 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 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 76168DE0760002-02
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, 76168DE0760002-02

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

$0.00, 0.00%

$0.00, 0.00%
Acupuncture
NO
Allergy Testing
YES

$0.00, 0.00%

0.00%
Bariatric Surgery
YES

$0.00, 0.00%

$0.00, 0.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

$0.00

100.00%
Chemotherapy
YES

$0.00, 0.00%

$0.00, 0.00%
Chiropractic Care

Limit: 30.0 Visit(s) per Benefit Period

YES

$0.00, 0.00%

$0.00, 0.00%
Clinical Trials
YES

$0.00, 0.00%

$0.00, 0.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

$0.00, 0.00%

$0.00, 0.00%
Dental Check-Up for Children

Limit: 1.0 Exam(s) per 6 Months

YES

$0.00

100.00%
Diabetes Care Management
YES

$0.00, 0.00%

$0.00, 0.00%
Diabetes Education
YES

$0.00

100.00%
Dialysis
YES

$0.00, 0.00%

$0.00, 0.00%
Durable Medical Equipment
YES

$0.00, 0.00%

$0.00, 0.00%
Emergency Room Services
YES

$0.00, 0.00%

$0.00, 0.00%
Emergency Transportation/Ambulance
YES

$0.00, 0.00%

$0.00, 0.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

$0.00

100.00%
Gender Affirming Care
NO
Generic Drugs
YES

$0.00, 0.00%

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

$0.00, 0.00%

$0.00, 0.00%
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

$0.00, 0.00%

$0.00, 0.00%
Home Health Care Services

Limit: 100.0 Visit(s) per Benefit Period

Aggregate with Visiting Nurse

YES

$0.00, 0.00%

$0.00, 0.00%
Hospice Services
YES

$0.00, 0.00%

$0.00, 0.00%
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

$0.00, 0.00%

$0.00, 0.00%
Infertility Treatment
YES

$0.00, 0.00%

$0.00, 0.00%
Infusion Therapy
YES

$0.00, 0.00%

$0.00, 0.00%
Inherited Metabolic Disorder - PKU
YES

$0.00, 0.00%

$0.00, 0.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

$0.00, 0.00%

$0.00, 0.00%
Inpatient Physician and Surgical Services
YES

$0.00, 0.00%

$0.00, 0.00%
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

$0.00, 0.00%

0.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

$0.00

100.00%
Mental/Behavioral Health Inpatient Services
YES

$0.00, 0.00%

$0.00, 0.00%
Mental/Behavioral Health Outpatient Services
YES

$0.00, 0.00%

$0.00, 0.00%
Non-Preferred Brand Drugs
YES

$0.00, 0.00%

100.00%
Nutritional Counseling
YES

$0.00

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
YES

$0.00

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

$0.00, 0.00%

$0.00, 0.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

$0.00, 0.00%

$0.00, 0.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Benefit Period

YES

$0.00, 0.00%

$0.00, 0.00%
Outpatient Surgery Physician/Surgical Services
YES

$0.00, 0.00%

$0.00, 0.00%
Preferred Brand Drugs
YES

$0.00, 0.00%

100.00%
Prenatal and Postnatal Care
YES

$0.00, 0.00%

$0.00, 0.00%
Preventive Care/Screening/Immunization
YES

$0.00

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

$0.00, 0.00%

$0.00, 0.00%
Private-Duty Nursing

Limit: 240.0 Hours per Benefit Period

Exclusions: Outpatient not covered

YES

$0.00, 0.00%

$0.00, 0.00%
Prosthetic Devices
YES

$0.00, 0.00%

$0.00, 0.00%
Radiation
YES

$0.00, 0.00%

$0.00, 0.00%
Reconstructive Surgery
YES

$0.00, 0.00%

$0.00, 0.00%
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

$0.00, 0.00%

$0.00, 0.00%
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

$0.00, 0.00%

$0.00, 0.00%
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
NO
Skilled Nursing Facility

Limit: 120.0 Days per Benefit Period

YES

$0.00, 0.00%

$0.00, 0.00%
Specialist Visit
YES

$0.00, 0.00%

$0.00, 0.00%
Specialty Drugs
YES

$0.00, 0.00%

100.00%
Substance Abuse Disorder Inpatient Services
YES

$0.00, 0.00%

$0.00, 0.00%
Substance Abuse Disorder Outpatient Services
YES

$0.00, 0.00%

$0.00, 0.00%
Transplant
YES

$0.00, 0.00%

$0.00, 0.00%
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

$0.00, 0.00%

$0.00, 0.00%
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

$0.00, 0.00%

$0.00, 0.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

$0.00

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

$0.00, 0.00%

0.00%

my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan Variant 76168DE0760002-02 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 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) 76168DE0760002-02
Plan Marketing Name my Blue Access PPO Standard Silver 5800
Plan Type PPO
Plan Variant Marketing Name my Blue Access PPO Standard Silver 5800 AIAN Zero
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 $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
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 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 $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $0
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $0
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 $0 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $0
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 $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $0
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 (76168DE0760002-02) 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 (76168DE0760002-02) 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 (76168DE0760002-02) 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 (76168DE0760002-02) 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 AIAN Zero Health Insurance Plan, Variant (76168DE0760002-02) offer Disease Management Programs for Asthma?

    Yes, the my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan Variant 76168DE0760002-02 offers Disease Management Program for Asthma.

    Does my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan, Variant (76168DE0760002-02) offer Disease Management Programs for Heart disease?

    Yes, the my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan Variant 76168DE0760002-02 offers Disease Management Program for Heart disease.

    Does my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan, Variant (76168DE0760002-02) offer Disease Management Programs for Depression?

    Yes, the my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan Variant 76168DE0760002-02 offers Disease Management Program for Depression.

    Does my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan, Variant (76168DE0760002-02) offer Disease Management Programs for Diabetes?

    Yes, the my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan Variant 76168DE0760002-02 offers Disease Management Program for Diabetes.

    Does my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan, Variant (76168DE0760002-02) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan Variant 76168DE0760002-02 offers Disease Management Program for High blood pressure & high cholesterol.

    Does my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan, Variant (76168DE0760002-02) offer Disease Management Programs for Low back pain?

    Yes, the my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan Variant 76168DE0760002-02 offers Disease Management Program for Low back pain.

    Does my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan, Variant (76168DE0760002-02) offer Disease Management Programs for Pregnancy?

    Yes, the my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan Variant 76168DE0760002-02 offers Disease Management Program for Pregnancy.

    Does my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan, Variant (76168DE0760002-02) offer Disease Management Programs for Weight loss programs?

    Yes, the my Blue Access PPO Standard Silver 5800 AIAN Zero Health Insurance Plan Variant 76168DE0760002-02 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