Blue Plus Metro MN Gold Prescription Copay $1100 Plan 455 - 57129MN0090016 Health Insurance Plan
HMO MINNESOTA health insurance plan with the Plan ID 57129MN0090016. The plan is called Blue Plus Metro MN Gold Prescription Copay $1100 Plan 455.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 80.73% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.27% 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 80.64% (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 19.36% 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 | 57129MN0090016 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Minnesota | ||||||||||||||||||
| Health Insurance Issuer | HMO MINNESOTA | ||||||||||||||||||
| Health Insurance Plan Variant | 57129MN0090016-03 | ||||||||||||||||||
| Provider Network(s) | ['MNN005'] | ||||||||||||||||||
| 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 | Standard On Exchange Plan - 57129MN0090016-01 |
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| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Blue Plus Metro MN Gold Prescription Copay $1100 AI/AN Limited Cost Share Reduction Plan 455b Health Insurance Plan Variant 57129MN0090016-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.806363371 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Pregnancy, Depression, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 99% |
| First Tier Utilization | 100% |
| Formulary ID | MNF003 |
| HIOS Product ID | 57129MN009 |
| Import Date | 2/12/2024 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 80.73% |
| Issuer ID | 57129 |
| 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 person not applicable | per group 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 | $1100 per person | $3300 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,100 |
| Medical EHB Deductible, Out of Network, Family | $20000 per person | $40000 per group |
| Medical EHB Deductible, Out of Network, Individual | $20,000 |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | MNN005 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Out of network benefits will be applied |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Out of network benefits will be applied |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 57129MN0090016-03 |
| Plan Marketing Name | Blue Plus Metro MN Gold Prescription Copay $1100 Plan 455 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Blue Plus Metro MN Gold Prescription Copay $1100 AI/AN Limited Cost Share Reduction Plan 455b |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MNS014 |
| Source Name | SERFF |
| Plan ID | 57129MN0090016 |
| State Code | MN |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family | per person not applicable | per group 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 | $7500 per person | $15000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Blue Plus Metro MN Gold Prescription Copay $1100 Plan 455 Health Insurance Plan, 57129MN0090016
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Blue Plus Metro MN Gold Prescription Copay $1100 Plan 455, 57129MN0090016 Health Insurance Plan, 57129MN0090016
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Does Blue Plus Metro MN Gold Prescription Copay $1100 Plan 455 Health Insurance Plan, 57129MN0090016 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (57129MN0090016) Health Insurance Plan, Variant (57129MN0090016-03) offer Disease Management Programs?
Does (57129MN0090016) Health Insurance Plan, Variant (57129MN0090016-03) have Out Of Country Coverage?
Does (57129MN0090016) Health Insurance Plan, Variant (57129MN0090016-03) have Out of Service Area Coverage?
Does (57129MN0090016) Health Insurance Plan, Variant (57129MN0090016-03) offer Disease Management Programs?
Does Blue Plus Metro MN Gold Prescription Copay $1100 AI/AN Limited Cost Share Reduction Plan 455b Health Insurance Plan, Variant (57129MN0090016-03) offer Disease Management Programs for Asthma?
Does Blue Plus Metro MN Gold Prescription Copay $1100 AI/AN Limited Cost Share Reduction Plan 455b Health Insurance Plan, Variant (57129MN0090016-03) offer Disease Management Programs for Heart disease?
Does Blue Plus Metro MN Gold Prescription Copay $1100 AI/AN Limited Cost Share Reduction Plan 455b Health Insurance Plan, Variant (57129MN0090016-03) offer Disease Management Programs for Depression?
Does Blue Plus Metro MN Gold Prescription Copay $1100 AI/AN Limited Cost Share Reduction Plan 455b Health Insurance Plan, Variant (57129MN0090016-03) offer Disease Management Programs for Diabetes?
Does Blue Plus Metro MN Gold Prescription Copay $1100 AI/AN Limited Cost Share Reduction Plan 455b Health Insurance Plan, Variant (57129MN0090016-03) 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