Silver 5000 Separate RX Deductible - 22013UT2630016 Health Insurance Plan
Regence BlueCross BlueShield of Utah health insurance plan with the Plan ID 22013UT2630016. The plan is called Silver 5000 Separate RX Deductible.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 69.15% (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 30.85% 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 | 22013UT2630016 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | Regence BlueCross BlueShield of Utah | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 22013UT2630016-00 | ||||||||||||||||||
| Provider Network(s) | ['UTN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 22013UT2630016-00 Standard On Exchange Plan - 22013UT2630016-01 Open to Indians below 300% FPL - 22013UT2630016-02 Open to Indians above 300% FPL - 22013UT2630016-03 73% AV Silver Plan - 22013UT2630016-04 |
||||||||||||||||||
| Last Plan Update Date | Tue, 17 Aug 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Silver 5000 Separate RX Deductible Health Insurance Plan Variant 22013UT2630016-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.691485984 |
| 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 Silver 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 | 20.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $4000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2000 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
| 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 |
| EHB Percent of Total Premium | 0.997 |
| First Tier Utilization | 100% |
| Formulary ID | UTF006 |
| Formulary URL | URL |
| HIOS Product ID | 22013UT263 |
| Import Date | 8/17/2021 20:00 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 22013 |
| Issuer Marketplace Marketing Name | Regence BlueCross BlueShield of Utah |
| 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 | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $10000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $5000 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $5,000 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | UTN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan ID (Standard Component ID with Variant) | 22013UT2630016-00 |
| Plan Marketing Name | Silver 5000 Separate RX Deductible |
| Plan Type | EPO |
| Plan Variant Marketing Name | Silver 5000 Separate RX Deductible |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,443 |
| SBC Scenario, Having a Baby, Copayment | $11 |
| SBC Scenario, Having a Baby, Deductible | $5,000 |
| SBC Scenario, Having a Baby, Limit | $61 |
| SBC Scenario, Having Diabetes, Coinsurance | $937 |
| SBC Scenario, Having Diabetes, Copayment | $384 |
| SBC Scenario, Having Diabetes, Deductible | $877 |
| SBC Scenario, Having Diabetes, Limit | $178 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $589 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,090 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | UTS001 |
| Source Name | SERFF |
| Plan ID | 22013UT2630016 |
| State Code | UT |
| 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 | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Silver 5000 Separate RX Deductible Health Insurance Plan, 22013UT2630016
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Silver 5000 Separate RX Deductible, 22013UT2630016 Health Insurance Plan, 22013UT2630016
-
Does Silver 5000 Separate RX Deductible Health Insurance Plan, 22013UT2630016 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (22013UT2630016) Health Insurance Plan, Variant (22013UT2630016-00) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (22013UT2630016) Health Insurance Plan, Variant (22013UT2630016-00) 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: Tue, 23 Apr 2024 07:07 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