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Regence Standard Gold Plan Legacy LHP - 77969OR5290007 Health Insurance Plan

Regence BlueCross BlueShield of Oregon health insurance plan with the Plan ID 77969OR5290007. The plan is called Regence Standard Gold Plan Legacy LHP.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.82% (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 18.18% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Field Data
Health Insurance Plan ID77969OR5290007
Health Insurance Plan Year2023
StateOregon
Health Insurance IssuerRegence BlueCross BlueShield of Oregon
Plan Formulary Description URLFormulary URL
Plan Marketing Materials URLMarketing URL
Last Plan Update DateWed, 17 Aug 2022 00:00 GMT
Last Import DateSun, 24 Sep 2023 09:34 GMT
Health Insurance Plan Variant77969OR5290007-00
 
Available Variants of the Health Plan

77969OR5290007-00

77969OR5290007-01

77969OR5290007-02

77969OR5290007-03

Regence Standard Gold Plan Legacy LHP Health Insurance Plan Variant 77969OR5290007-00 Attributes

Plan Attribute Value
AV Calculator Output Number0.818197942
Begin Primary Care Cost-Sharing After Number Of Visits0
Begin Primary Care Deductible Coinsurance After Number Of Copays0
Business Year2023
Child-Only OfferingAllows Adult and Child-Only
Composite Rating OfferedNo
CSR Variation TypeStandard Gold Off Exchange Plan
Drug EHB Deductible, Combined In/Out of Network, Family Per Groupper group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Personper person not applicable
Drug EHB Deductible, Combined In/Out of Network, IndividualNot Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance20.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group$0 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person$0 per person
Drug EHB Deductible, In Network (Tier 1), Individual$0
DEHBDedOutOfNetFamilyPerGroupper group not applicable
DEHBDedOutOfNetFamilyPerPersonper person not applicable
Drug EHB Deductible, Out of Network, IndividualNot Applicable
Dental Only PlanNo
Design TypeDesign 3
EHB Percent of Total Premium 0.996
First Tier Utilization100%
Formulary IDORF011
Formulary URLURL
HIOS Product ID77969OR529
Import Date8/17/2022 20:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment$0.00
Inpatient Copayment Maximum Days0
HSA EligibleNo
New/Existing PlanExisting
Notice Required for PregnancyNo
Is a Referral Required for Specialist?No
Issuer ID77969
Issuer Marketplace Marketing NameRegence BlueCross BlueShield of Oregon
Market CoverageIndividual
Medical Drug Deductibles IntegratedNo
Medical Drug Maximum Out of Pocket IntegratedYes
Medical EHB Deductible, Combined In/Out of Network, Family Per Groupper group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Personper person not applicable
Medical EHB Deductible, Combined In/Out of Network, IndividualNot Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance20.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group$3600 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person$1800 per person
Medical EHB Deductible, In Network (Tier 1), Individual$1,800
Medical EHB Deductible, Out of Network, Family Per Groupper group not applicable
Medical EHB Deductible, Out of Network, Family Per Personper person not applicable
Medical EHB Deductible, Out of Network, IndividualNot Applicable
Metal LevelGold
Multiple In Network TiersNo
National NetworkNo
Network IDORN002
Out of Country CoverageNo
Out of Service Area CoverageNo
Plan BrochureURL
Plan Effective Date1/1/2023
Plan Expiration Date12/31/2023
Plan ID (Standard Component ID with Variant) 77969OR5290007-00
Plan Marketing NameRegence Standard Gold Plan Legacy LHP
Plan TypeEPO
Plan Variant Marketing NameRegence Standard Gold Plan Legacy LHP
QHP/Non QHPBoth
SBC Scenario, Having a Baby, Coinsurance$2,143
SBC Scenario, Having a Baby, Copayment$11
SBC Scenario, Having a Baby, Deductible$1,800
SBC Scenario, Having a Baby, Limit$61
SBC Scenario, Having Diabetes, Coinsurance$0
SBC Scenario, Having Diabetes, Copayment$684
SBC Scenario, Having Diabetes, Deductible$877
SBC Scenario, Having Diabetes, Limit$178
SBC Scenario, Treatment of a Simple Fracture, Coinsurance$118
SBC Scenario, Treatment of a Simple Fracture, Copayment$285
SBC Scenario, Treatment of a Simple Fracture, Deductible$1,500
SBC Scenario, Treatment of a Simple Fracture, Limit$0
Service Area IDORS002
Source NameSERFF
Specialty Drug Maximum Coinsurance$500
Plan ID77969OR5290007
State CodeOR
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Groupper group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Personper person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, IndividualNot Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group$14600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person$7300 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual$7,300
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Groupper group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Personper person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, IndividualNot Applicable
Unique Plan DesignNo
URL for Enrollment PaymentURL
URL for Summary of Benefits & CoverageURL
Wellness Program OfferedNo

Copay & Coinsurance of Regence Standard Gold Plan Legacy LHP Health Insurance Plan, 77969OR5290007

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

Frequently Asked Questions(FAQ) about Regence Standard Gold Plan Legacy LHP, 77969OR5290007 Health Insurance Plan, 77969OR5290007

Does Regence Standard Gold Plan Legacy LHP Health Insurance Plan, 77969OR5290007 support Mail Ordering?

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

Does (77969OR5290007) Health Insurance Plan, Variant (77969OR5290007-00) have Out Of Country Coverage?

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

Does (77969OR5290007) Health Insurance Plan, Variant (77969OR5290007-00) 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: Sun, 24 Sep 2023 09:34 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