Anthem Gold Blue Connection EPO 2000/0%/6500 RxD - 57601NH0490011 Health Insurance Plan
Anthem Health Plans of NH(Anthem BCBS) health insurance plan with the Plan ID 57601NH0490011. The plan is called Anthem Gold Blue Connection EPO 2000/0%/6500 RxD.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.34% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.66% 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 79.08% (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 20.92% 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 | 57601NH0490011 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | New Hampshire | ||||||||||||||||||
| Health Insurance Issuer | Anthem Health Plans of NH(Anthem BCBS) | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 57601NH0490011-00 | ||||||||||||||||||
| Provider Network(s) | PARTICIPATING | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Tue, 15 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Anthem Gold Blue Connection EPO 2000/0%/6500 RxD Health Insurance Plan, 57601NH0490011-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Cost share driven by Provider setting. |
YES | $500.00 Copay after deductible |
100.00% |
| 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 | $500.00 Copay after deductible |
100.00% |
| Acupuncture
Limit: 20.0 Visit(s) per Benefit Period Cost share driven by Provider setting. Limit is combined across professional visits and outpatient facilities. |
YES | $20.00 |
100.00% |
| Allergy Testing
Cost share shown is for professional office-based services. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| 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 | 0.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 36.0 Visit(s) per Benefit Period Benefit limit does not apply to Osteopathic manipulative treatment.Limit is combined across professional visits and outpatient facilities.Cost share driven by provider/setting. Cost share shown is for professional office-based services. |
YES | $20.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Benefit Period |
YES | No Charge after deductible |
100.00% |
| Diabetes Education
Cost share driven by provider/setting. Cost share shown is for professional office-based services. |
YES | $40.00 |
100.00% |
| Dialysis
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| 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 | 0.00% Coinsurance after deductible |
0.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Eye glasses or Contact Lenses are covered once per benefit period for INN Services. |
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.Tier 1 and tier 2 contains preventive drugs that can incur cost sharing for different circumstances. |
YES | Tier 1: $20.00 Tier 2: $30.00 |
100.00% |
| 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 across professional visits and outpatient facilities.Cost share driven by provider/setting. Cost share shown is for professional office-based services. |
YES | $20.00 |
100.00% |
| Hearing Aids
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Coverage excludes Private Duty nursing services. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Cost share driven by Provider setting. |
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Cost share driven by Provider setting. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| 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 | $500.00 Copay after deductible |
100.00% |
| Infusion Therapy
Cost share driven by Provider setting. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| 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 | 0.00% Coinsurance after deductible |
100.00% |
| 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 | 0.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Cost share shown is for professional office-based services. |
YES | No Charge |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost share driven by Provider setting. |
YES | $20.00 |
100.00% |
| 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 |
100.00% |
| Nutritional Counseling
|
YES | $20.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $20.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Cost share driven by Provider setting. |
YES | $500.00 Copay after deductible |
100.00% |
| 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 across professional visits and outpatient facilities.Cost share driven by provider/setting. Cost share shown is for professional office-based services. |
YES | $20.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Cost share driven by Provider setting. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| 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.Tier 1 and tier 2 contains preventive drugs that can incur cost sharing for different circumstances. |
YES | Tier 1: $60.00 Copay after deductible Tier 2: $70.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
In network preventive prenatal and postnatal services are covered at 100%. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $20.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Cost share driven by Provider setting. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| 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.Cost share driven by provider/setting. Cost share shown is for professional office-based services. |
YES | $20.00 |
100.00% |
| 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 across professional visits and outpatient facilities.Cost share driven by provider/setting. Cost share shown is for professional office-based services. |
YES | $20.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per Benefit Period Eye exams are covered once per benefit period for INN Services. |
YES | $20.00 |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Benefit Period Eye exams are covered once per benefit period for INN Services. ? |
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 driven by provider/setting. |
YES | $40.00 |
100.00% |
| Skilled Nursing Facility
Limit: 100.0 Days per Benefit Period Limited to 100 days per benefit period for Inpatient Rehabilitation services. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $40.00 |
100.00% |
| Specialty Drugs
|
YES | Tier 1: 40.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Cost share driven by Provider setting. |
YES | $20.00 |
100.00% |
| Transplant
Exclusions: Meals relative to transportation and lodging are excluded. |
YES | 0.00% 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 | $500.00 Copay after deductible |
100.00% |
| Urgent Care Centers or Facilities
Costs may vary by site of service. |
YES | $100.00 |
$100.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Covered under preventive care. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Cost share driven by Provider setting. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Anthem Gold Blue Connection EPO 2000/0%/6500 RxD Health Insurance Plan Variant 57601NH0490011-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7908184008059609 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold 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 | 40.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $500 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $250 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $250 |
| Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 40.00% |
| Drug EHB Deductible, In Network (Tier 2), Family Per Group | $500 per group |
| Drug EHB Deductible, In Network (Tier 2), Family Per Person | $250 per person |
| Drug EHB Deductible, In Network (Tier 2), Individual | $250 |
| 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 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pregnancy |
| First Tier Utilization | 52% |
| Formulary ID | NHF004 |
| Formulary URL | URL |
| HIOS Product ID | 57601NH049 |
| HSA/HRA Employer Contribution | No |
| Import Date | 2023-08-15 20:02:25 |
| 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 Actuarial Value | 78.34% |
| Issuer ID | 57601 |
| Issuer Marketplace Marketing Name | Anthem Blue Cross and Blue Sheld |
| Market Coverage | SHOP (Small Group) |
| 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 | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $4000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $2000 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $2,000 |
| Medical EHB Deductible, In Network (Tier 2), Default Coinsurance | 0.00% |
| Medical EHB Deductible, In Network (Tier 2), Family Per Group | $4000 per group |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | $2000 per person |
| Medical EHB Deductible, In Network (Tier 2), Individual | $2,000 |
| 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 | Gold |
| Multiple In Network Tiers | Yes |
| National Network | Yes |
| Network ID | NHN002 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Urgent/Emergency Coverage Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Blue High Performance Network |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 57601NH0490011-00 |
| Plan Marketing Name | Anthem Gold Blue Connection EPO 2000/0%/6500 RxD |
| Plan Type | EPO |
| Plan Variant Marketing Name | Anthem Gold Blue Connection EPO 2000/0%/6500 RxD |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $2,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,600 |
| SBC Scenario, Having Diabetes, Deductible | $250 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 48% |
| Service Area ID | NHS003 |
| Source Name | SERFF |
| Specialty Drug Maximum Coinsurance | $650 |
| Plan ID | 57601NH0490011 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $13000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $13000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $6500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $6,500 |
| 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 | Yes |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Anthem Gold Blue Connection EPO 2000/0%/6500 RxD Health Insurance Plan, 57601NH0490011
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Anthem Gold Blue Connection EPO 2000/0%/6500 RxD, 57601NH0490011 Health Insurance Plan, 57601NH0490011
-
Does Anthem Gold Blue Connection EPO 2000/0%/6500 RxD Health Insurance Plan, 57601NH0490011 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (57601NH0490011) Health Insurance Plan, Variant (57601NH0490011-00) offer Disease Management Programs?
Does (57601NH0490011) Health Insurance Plan, Variant (57601NH0490011-00) have Out Of Country Coverage?
Does (57601NH0490011) Health Insurance Plan, Variant (57601NH0490011-00) have Out of Service Area Coverage?
Does (57601NH0490011) Health Insurance Plan, Variant (57601NH0490011-00) offer Disease Management Programs?
Does Anthem Gold Blue Connection EPO 2000/0%/6500 RxD Health Insurance Plan, Variant (57601NH0490011-00) offer Disease Management Programs for Asthma?
Does Anthem Gold Blue Connection EPO 2000/0%/6500 RxD Health Insurance Plan, Variant (57601NH0490011-00) offer Disease Management Programs for Heart disease?
Does Anthem Gold Blue Connection EPO 2000/0%/6500 RxD Health Insurance Plan, Variant (57601NH0490011-00) offer Disease Management Programs for Depression?
Does Anthem Gold Blue Connection EPO 2000/0%/6500 RxD Health Insurance Plan, Variant (57601NH0490011-00) offer Disease Management Programs for Diabetes?
Does Anthem Gold Blue Connection EPO 2000/0%/6500 RxD Health Insurance Plan, Variant (57601NH0490011-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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