| Field | Data |
|---|---|
| Health Insurance Plan ID | 76168DE0760002 |
| Health Insurance Plan Year | 2023 |
| State | Delaware |
| Health Insurance Issuer | Highmark BCBSD Inc. |
| Last Plan Update Date | Wed, 10 Aug 2022 00:00 GMT |
| Last Import Date | Sun, 28 May 2023 07:51 GMT |
| Health Insurance Plan Variant | 76168DE0760002-04 |
| Available Variants of the Health Plan | |
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.734183135 |
| 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 | 73% AV Level Silver 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) | 76168DE0760002-04 |
| Plan Marketing Name | my Blue Access PPO Standard Silver 5800 |
| Plan Type | PPO |
| Plan Variant Marketing Name | my Blue Access PPO Standard Extra Savings Silver 4100 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,000 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $4,100 |
| 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 | $8200 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4100 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,100 |
| TEHBDedOutOfNetFamilyPerGroup | $16400 per group |
| TEHBDedOutOfNetFamilyPerPerson | $8200 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $8,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $14400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $28800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $14400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $14,400 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
| 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 (76168DE0760002-04) 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 (76168DE0760002-04) 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 (76168DE0760002-04) 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 (76168DE0760002-04) 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 Extra Savings Silver 4100 Health Insurance Plan, Variant (76168DE0760002-04) offer Disease Management Programs for Asthma?
Yes, the my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan Variant 76168DE0760002-04 offers Disease Management Program for Asthma.
Does my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan, Variant (76168DE0760002-04) offer Disease Management Programs for Heart disease?
Yes, the my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan Variant 76168DE0760002-04 offers Disease Management Program for Heart disease.
Does my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan, Variant (76168DE0760002-04) offer Disease Management Programs for Depression?
Yes, the my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan Variant 76168DE0760002-04 offers Disease Management Program for Depression.
Does my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan, Variant (76168DE0760002-04) offer Disease Management Programs for Diabetes?
Yes, the my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan Variant 76168DE0760002-04 offers Disease Management Program for Diabetes.
Does my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan, Variant (76168DE0760002-04) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan Variant 76168DE0760002-04 offers Disease Management Program for High blood pressure & high cholesterol.
Does my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan, Variant (76168DE0760002-04) offer Disease Management Programs for Low back pain?
Yes, the my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan Variant 76168DE0760002-04 offers Disease Management Program for Low back pain.
Does my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan, Variant (76168DE0760002-04) offer Disease Management Programs for Pain management?
Yes, the my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan Variant 76168DE0760002-04 offers Disease Management Program for Pain management.
Does my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan, Variant (76168DE0760002-04) offer Disease Management Programs for Pregnancy?
Yes, the my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan Variant 76168DE0760002-04 offers Disease Management Program for Pregnancy.
Does my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan, Variant (76168DE0760002-04) offer Disease Management Programs for Weight loss programs?
Yes, the my Blue Access PPO Standard Extra Savings Silver 4100 Health Insurance Plan Variant 76168DE0760002-04 offers Disease Management Program for Weight loss programs.
Disclaimer: This is based on the import(Date: Sun, 28 May 2023 07:51 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