Anthem Health Plans of NH(Anthem BCBS) health insurance plan with the Plan ID 57601NH0350026. The plan is called Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.95% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.05% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.83% (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 35.17% 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 | 57601NH0350026 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | New Hampshire | ||||||||||||||||||
Health Insurance Issuer | Anthem Health Plans of NH(Anthem BCBS) | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Health Insurance Plan Variant | 57601NH0350026-00 | ||||||||||||||||||
Provider Network(s) | ['NHN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Aug 2024 06:14 GMT). |
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Available Variants of the Health Plan | |||||||||||||||||||
Last Plan Update Date | Mon, 22 May 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
Cost share driven by Provider setting. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Accidental Dental
Benefits are available for dental work that is Medically Necessary due to an accidental injury to sound natural teeth and gums when the course of treatment for the accidental injury is received or authorized within 3 months of the date of the injury. Cost share is driven by provider/setting. |
YES | $60.00 Copay after deductible |
45.00% Coinsurance after deductible |
Acupuncture
Limit: 20.0 Visit(s) per Benefit Period Limit is combined in network and out of network across all outpatient settings. Cost share driven by Provider setting. |
YES | $40.00 Copay after deductible |
45.00% Coinsurance after deductible |
Allergy Testing
|
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Bariatric Surgery
Benefits are available for bariatric surgery that is Medically Necessary for the treatment of diseases and ailments caused by or resulting from obesity or morbid obesity. Cost share driven by Provider setting. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Basic Dental Care - Adult
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
Basic Dental Care - Child
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Chiropractic Care
Limit: 36.0 Visit(s) per Benefit Period Limit is combined in network and out of network across all outpatient settings. Benefit limit does not apply to Osteopathic manipulative treatment. Cost share driven by Provider setting. |
YES | $40.00 Copay after deductible |
45.00% Coinsurance after deductible |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Dental Check-Up for Children
Limit: 2.0 Visit(s) per Benefit Period Limit is combined in network and out of network across all outpatient settings. Cost share driven by provider/setting. |
YES | No Charge |
No Charge |
Diabetes Education
Cost share driven by Provider setting. |
YES | $60.00 Copay after deductible |
45.00% Coinsurance after deductible |
Dialysis
|
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Durable Medical Equipment
|
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Emergency Room Services
Emergency Room copay is waived if admitted to hospital. |
YES | $350.00 Copay after deductible |
$350.00 Copay after deductible |
Emergency Transportation/Ambulance
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Limited reimbursement up to maximum allowable for all services. Child frames and lenses or contact lenses are covered once per benefit period. Cost share is driven by provider/setting. Limit is combined in network and out of network. |
YES | No Charge |
100.00% |
Gender Affirming Care
|
NO | ||
Generic Drugs
Members can choose to receive a 90-day supply at retail pharmacies. When there is a copay, the copay is three times the standard retail copayment. |
YES | Tier 1: $25.00 Copay after deductible Tier 2: $35.00 Copay after deductible |
50.00% Coinsurance after deductible |
Habilitation Services
Limit: 60.0 Visit(s) per Benefit Period Exclusions: The plan excludes coverage of Maintenance Therapy, defined as a treatment given when no further gains are clear or likely to occur. Maintenance therapy includes care that helps you keep your current level of function and prevents loss of that function, but does not result in any change for the better. Limited to 60 combined visits for Physical, Occupational, and Speech Therapy benefit. Limit is combined in network and out of network across all outpatient settings. Cost share driven by Provider setting. |
YES | $40.00 Copay after deductible |
45.00% Coinsurance after deductible |
Hearing Aids
|
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Home Health Care Services
Coverage excludes Private Duty nursing services. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Hospice Services
Cost share driven by Provider setting. |
YES | No Charge after deductible |
45.00% Coinsurance after deductible |
Imaging (CT/PET Scans, MRIs)
Cost share driven by Provider setting. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Infertility Treatment
Covered Services include diagnostic tests to find the cause of infertility, such as diagnostic laparoscopy, endometrial biopsy, and semen analysis. Benefits also include services to treat the underlying medical conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). Cost share driven by Provider setting. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Inpatient Hospital Services (e.g., Hospital Stay)
Limited to 100 days per benefit period for Inpatient Rehabilitation services. Limit applies to Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis) |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Inpatient Physician and Surgical Services
Limited to 100 days per benefit period for Inpatient Rehabilitation services. Limit applies to Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis) |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Laboratory Outpatient and Professional Services
Cost share driven by Provider setting. |
YES | No Charge after deductible |
45.00% Coinsurance after deductible |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Major Dental Care - Child
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Mental/Behavioral Health Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Mental/Behavioral Health Outpatient Services
Cost share driven by Provider setting. |
YES | $40.00 Copay after deductible |
45.00% Coinsurance after deductible |
Non-Preferred Brand Drugs
Members can choose to receive a 90-day supply at retail pharmacies. |
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Nutritional Counseling
Covered under preventive guidelines and for diabetes. |
YES | $40.00 Copay after deductible |
40.00% Coinsurance after deductible |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $40.00 Copay after deductible |
45.00% Coinsurance after deductible |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Cost share driven by Provider setting. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Benefit Period Limited to 60 combined visits for Physical, Occupational, and Speech Therapy benefit. Limit is combined in network and out of network across all outpatient settings. Cost share driven by Provider setting. |
YES | $40.00 Copay after deductible |
45.00% Coinsurance after deductible |
Outpatient Surgery Physician/Surgical Services
Cost share driven by Provider setting. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Preferred Brand Drugs
Members can choose to receive a 90-day supply at retail pharmacies. When there is a copay, the copay is three times the standard retail copayment. |
YES | Tier 1: $80.00 Copay after deductible Tier 2: $90.00 Copay after deductible |
50.00% Coinsurance after deductible |
Prenatal and Postnatal Care
In network preventive prenatal and postnatal services are covered at 100%. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Preventive Care/Screening/Immunization
|
YES | No Charge |
45.00% Coinsurance after deductible |
Primary Care Visit to Treat an Injury or Illness
PCP copay may be discounted depending upon provider selected. |
YES | $40.00 Copay after deductible |
45.00% Coinsurance after deductible |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
|
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Radiation
|
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Reconstructive Surgery
Cost share driven by Provider setting. |
YES | 25.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Benefit Period Limited to 60 combined visits for rehabilitative Physical, Occupational, and Speech Therapy. Limit is combined in network and out of network across all outpatient settings. Cost share driven by Provider setting. |
YES | $40.00 Copay after deductible |
45.00% Coinsurance after deductible |
Rehabilitative Speech Therapy
Limit: 60.0 Visit(s) per Benefit Period Limit is 60 combined visits for rehabilitative Physical, Occupational, and Speech Therapy benefit. Limit is combined in network and out of network across all outpatient settings. Cost share driven by Provider setting. |
YES | $40.00 Copay after deductible |
45.00% Coinsurance after deductible |
Routine Dental Services (Adult)
|
YES | No Charge |
No Charge |
Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per Benefit Period A limited reimbursement of $30 applies to Routine Eye Exams for Adults out of network. Limit is combined in network and out of network. |
YES | $20.00 |
100.00% |
Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Benefit Period Limited reimbursement up to maximum allowable for all services. Eye exams are covered once per benefit period.? Limit is combined in network and out of network. |
YES | No Charge |
100.00% |
Routine Foot Care
Exclusions: The following services are excluded from routine foot care. Cutting or removing corns and calluses, trimming nails, cleaning and preventive foot care including but not limited to; cleaning and soaking the feet, applying skin creams to care for skin tone and other services that are given when there is not an illness, injury or symptom involving the foot. Covered if medically necessary for illness or injury. Cost share is driven by provider/setting. |
YES | $60.00 Copay after deductible |
45.00% Coinsurance after deductible |
Skilled Nursing Facility
Limit: 100.0 Days per Benefit Period Limited to 100 days per benefit period for Inpatient Rehabilitation services. Limit is combined in network and out of network. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Specialist Visit
|
YES | $60.00 Copay after deductible |
45.00% Coinsurance after deductible |
Specialty Drugs
|
YES | Tier 1: 40.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Substance Abuse Disorder Outpatient Services
Cost share driven by Provider setting. |
YES | $40.00 Copay after deductible |
45.00% Coinsurance after deductible |
Transplant
Exclusions: Meals relative to transportation and lodging are excluded in and out of network. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
Coverage includes TMJ surgery and limited non-surgical treatment. Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. |
YES | 25.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Urgent Care Centers or Facilities
Costs may vary by site of service. |
YES | $100.00 Copay after deductible |
45.00% Coinsurance after deductible |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
Covered under preventive care. |
YES | No Charge |
45.00% Coinsurance after deductible |
X-rays and Diagnostic Imaging
Cost share driven by Provider setting. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.64830992 |
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 Bronze Off Exchange Plan |
Dental Only Plan | No |
Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pregnancy |
First Tier Utilization | 51% |
Formulary ID | NHF003 |
Formulary URL | URL |
HIOS Product ID | 57601NH035 |
HSA/HRA Employer Contribution | No |
Import Date | 5/22/2023 20:01 |
Inpatient Copayment Maximum Days | 0 |
HSA Eligible | Yes |
New/Existing Plan | New |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | No |
Issuer Actuarial Value | 64.95% |
Issuer ID | 57601 |
Issuer Marketplace Marketing Name | Anthem Blue Cross and Blue Sheld |
Market Coverage | SHOP (Small Group) |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Expanded Bronze |
Multiple In Network Tiers | Yes |
National Network | Yes |
Network ID | NHN001 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Full Access |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Standard Bluecard PPO Network |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 57601NH0350026-00 |
Plan Marketing Name | Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH |
Plan Type | PPO |
Plan Variant Marketing Name | Anthem Bronze Preferred Blue PPO 5000/25%/7450 w/HSA WH |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $1,900 |
SBC Scenario, Having a Baby, Copayment | $10 |
SBC Scenario, Having a Baby, Deductible | $5,000 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $200 |
SBC Scenario, Having Diabetes, Deductible | $5,000 |
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 | $2,800 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Second Tier Utilization | 49% |
Service Area ID | NHS002 |
Source Name | SERFF |
Specialty Drug Maximum Coinsurance | $650 |
Plan ID | 57601NH0350026 |
State Code | NH |
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 | 25.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $10000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5000 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,000 |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 25.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $10000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $5000 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $5,000 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $20000 per group |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $10000 per person |
Combined Medical and Drug EHB Deductible, Out of Network, Individual | $10,000 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $14900 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7450 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,450 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $14900 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $7450 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $7,450 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $29800 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $14900 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $14,900 |
Unique Plan Design | Yes |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | No |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 20 Aug 2024 06:14 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