Blue Portfolio HSA Bronze - Neighborhood Network - 53901AZ1420066 Health Insurance Plan
Blue Cross and Blue Shield of Arizona, Inc. health insurance plan with the Plan ID 53901AZ1420066. The plan is called Blue Portfolio HSA Bronze - Neighborhood Network.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.97% (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 36.03% 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 | 53901AZ1420066 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Arizona | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross and Blue Shield of Arizona, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 53901AZ1420066-01 | ||||||||||||||||||
| Provider Network(s) | NEIGHBORHOOD | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 53901AZ1420066-00 Standard On Exchange Plan - 53901AZ1420066-01 |
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| Last Plan Update Date | Tue, 17 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 24 Dec 2024 06:21 GMT |
Benefits of Blue Portfolio HSA Bronze - Neighborhood Network Health Insurance Plan, 53901AZ1420066-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Benefits are payable for the services of a Physician, dentist, or dental surgeon, provided the services are rendered for treatment of an accidental injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident. |
YES | No Charge after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
100.00% |
| Bariatric Surgery
The following bariatric surgery procedures are covered: open roux-en-y gastric bypass (RYGBP), laparoscopic roux-en-y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), open biliopancreatic diversion with duodenal switch (BPD/DS), laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS), and laparoscopic sleeve gastrectomy (LSG) 1. The patient must have a body-mass index (BMI) greater than equal to 35.; 2. Have at least one co-morbidity related to obesity.; 3. Previously unsuccessful with medical treatment for obesity. The following medical information must be documented in the patient's medical record: Active participation within the last two years in one physician?supervised weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of all of the following components: a. Weight; b. Current dietary program; c. Physical activity (e.g., exercise program); 4. In addition, the procedure must be performed at an approved BlueDistinction facility for bariatric surgery; 5. The member must be 18 years or older, or have reached full expected skeletal growth. |
YES | $1000.00 Copay with deductible, No Charge after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | No Charge after deductible |
100.00% |
| Chemotherapy
|
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year HMOs may limit chiropractic visits to 20. |
YES | No Charge after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Newborn benefits do not apply to the newly born child of an Eligible Dependent unless placement with the contract holder or covered spouse is confirmed through a court order or legal guardianship. |
YES | No Charge after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year Limit of 2 dental check-ups & cleanings per calendar year. |
YES | No Charge after deductible |
100.00% |
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
Benefits are limited to one (1) manual or electric (not hospital grade) breast pump and breast pump supplies per member, per calendar year. Benefits are limited to one (1) set of new and four (4) replacement sets of compression garments for the treatment of lymphedema per member, per calendar year. Benefits are limited to one (1) wig and one (1) hairpiece per member, per calendar year. |
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Limit of 1 pair of glasses or contact lenses per calendar year. |
YES | No Charge after deductible |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved. |
YES | No Charge after deductible |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Year Exclusions: Visit limit is separate from outpatient rehabilitation service limit. Excludes group therapy, private duty nursing, and custodial care. Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical, speech, occupational, cardiac, cognitive and pulmonary habilitation therapy for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | No Charge after deductible |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per Benefit Period Exclusions: Excludes disposable hearing aids, ear molds, batteries or battery replacements for hearing aids other than cochlear implants. Hearing aid devices limited to one per ear, per Calendar Year when determined to be medically necessary by the Medical Management Organization. |
YES | No Charge after deductible |
100.00% |
| Home Health Care Services
Limit: 42.0 Visit(s) per Year Exclusions: Excludes respite care, custodial care, private duty nursing. 1. The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.; 2. The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.; 3.The home health agency delivering care must be certified within the state the care is received.; 4. The care that is being provided is not custodial care. A Home Health visit is considered to be up to four hours of services. |
YES | No Charge after deductible |
100.00% |
| Hospice Services
Exclusions: Excludes respite care. The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live. |
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Infusion/IV Therapy in an Outpatient setting including, but not limited to: Inflixima/b (Remicade), Alefacept (Amevive), and Etanercept (Enbrel). |
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
Exclusions: Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs. |
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs. Counseling and psychiatric telehealth consultations available with BlueCare Anywhere - see SBC for more information. |
YES | No Charge after deductible |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved. |
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
Covered when dietary adjustment has a therapeutic role of a diagnosed chronic disease/condition, including but not limited to:1. Morbid obesity 2. Diabetes3. Cardiovascular disease 4. Hypertension 5. Kidney disease 6. Eating disorders 7. Gastrointestinal disorders 8. Food allergies 9. Hyperlipidemia |
YES | No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | No Charge after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Exclusions: Visit limit is separate from habilitation service limit. Excludes group therapy, private duty nursing, and custodial care. Short-term rehabilitative therapy includes services in an outpatient facility or physician?s office that is part of a rehabilitation program. These services may include physical, speech, occupational, cardiac rehabilitation, cognitive and pulmonary rehabilitation therapy. Visit limit is for all therapy types combined. |
YES | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved. |
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Limit: 1.0 Exam(s) per Year Benefits are limited to one (1) preventive physical exam per member, per calendar year, unless additional visits are necessary for the member to obtain all covered Preventive Services. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
24/7 online doctor visits available with BlueCare Anywhere - see SBC for more information. |
YES | No Charge after deductible |
100.00% |
| Private-Duty Nursing
Private hospital rooms and/or private duty nursing are only available during inpatient stays and determined to be medically appropriate by the Plan. Custodial Nursing is not covered by the Plan. |
YES | No Charge after deductible |
100.00% |
| Prosthetic Devices
Exclusions: Excludes biomechanical devices (external prosthetic device operated through or in conjunction with nerve conduction or other electrical impulses). The Plan covers the initial purchase and fitting of external prosthetic devices which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, injury, congenital defect, or alopecia as a result of chemotherapy, radiation therapy, and second or third degree burns. External prosthetic appliances shall include artificial arms and legs, wigs, hair pieces and terminal devices such as a hand or hook. Wigs and hair pieces are limited to one per Plan Year. Members must provide a valid prescription verifying diagnosis of alopecia as a result of chemotherapy, radiation therapy, second or third degree burns with a submitted claim for coverage. All other diagnosis are excluded. Replacement of artificial arms and legs and terminal devices are covered only if necessitated by normal anatomical growth or as a result of wear and tear. |
YES | No Charge after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: Excludes cosmetic surgery and services except for breast reconstruction following medically necessary mastectomy. Following a mastectomy, the following services and supplies are covered:1. Surgical services for reconstruction of the breast on which the mastectomy was performed; 2. Surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance; 3. Post-operative breast prostheses; and 4. Mastectomy bras/camisoles and external prosthetics that meet external prosthetic placement needs. During all stages of mastectomy, treatments of physical complications, including lymphedema, are covered. Cosmetic Surgery is covered for reconstructive surgery that constitutes necessary care and treatment of medically diagnosed services required for the prompt repair of accidental injury and any other services required by law. Issuer covers reconstruction of congenital defects and birth abnormalities in accordance with its medical coverage guidelines and/or when required by applicable law. Issuer covers medically necessary complications of breast implants / pectoral implants. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Year Exclusions: Excludes group therapy, private duty nursing, and custodial care. Visit limit is for multiple therapy types combined (PT, OT, ST, CT and Cardiac and Pulmonary Rehabilitative Visits). |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 60.0 Visit(s) per Year Exclusions: Excludes group therapy, private duty nursing, and custodial care. Visit limit is for multiple therapy types combined (PT, OT, ST, CT and Cardiac and Pulmonary Rehabilitative Visits). |
YES | No Charge after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year Limit of 1 routine vision exam per calendar year. |
YES | No Charge after deductible |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 90.0 Days per Year 90 combined SNF and inpatient extended active rehabilitation days per calendar year. |
YES | No Charge after deductible |
100.00% |
| Specialist Visit
|
YES | No Charge after deductible |
100.00% |
| Specialty Drugs
Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved. |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs. |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs. |
YES | No Charge after deductible |
100.00% |
| Transplant
Travel & lodging expenses are limited to $10,000 per transplant. Travel and lodging are not covered if the Member is a donor. Organ transplant services include the recipient's medical, surgical and hospital services; inpatient immunosuppressive medications; and costs for organ procurement. Transplant services are covered only if they are required to perform human to human organ or tissue transplants, such as:1. Allogeneic bone marrow/stem cell;2. Autologous bone marrow/stem cell;3. Cornea;4. Heart;5. Heart/lung;6. Kidney;7. Kidney/pancreas;8. Liver;9. Lung;10. Pancreas;11. Small bowel/liver; or 12. Kidney/liver. Organ transplant coverage will apply only to non-experimental transplants for the specific diagnosis. Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary. |
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Benefits are payable for covered services and supplies which are necessary to treat TMJ disorder. |
YES | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Well Child visits and immunizations are covered as recommended by the American Academy of Pediatrics. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
100.00% |
Blue Portfolio HSA Bronze Neighborhood Health Insurance Plan Variant 53901AZ1420066-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.6397370332054311 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | AZF008 |
| Formulary URL | URL |
| HIOS Product ID | 53901AZ142 |
| Import Date | 2024-09-17 01:02:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | Yes |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 53901 |
| Issuer Marketplace Marketing Name | Blue Cross Blue Shield of Arizona |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | AZN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergencies Only. Authorization required for non-emergent services. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergencies, Urgent Care and Authorized Follow-up Care. Urgent Care and Authorized Follow-up Care covered only through contracted providers. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 53901AZ1420066-01 |
| Plan Level Exclusions | Non-covered services and any services related to or associated with non-covered services, non-medically necessary services, and all other benefit specific and general exclusions and limitations listed in the benefit book. This exclusion does not apply to services required by federal or state law to be covered. |
| Plan Marketing Name | Blue Portfolio HSA Bronze - Neighborhood Network |
| Plan Type | HMO |
| Plan Variant Marketing Name | Blue Portfolio HSA Bronze Neighborhood |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,050 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,400 |
| 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 |
| Service Area ID | AZS006 |
| Source Name | HIOS |
| Plan ID | 53901AZ1420066 |
| State Code | AZ |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $14100 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7050 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,050 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $14100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7050 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,050 |
| 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 Blue Portfolio HSA Bronze - Neighborhood Network Health Insurance Plan, 53901AZ1420066
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Portfolio HSA Bronze - Neighborhood Network, 53901AZ1420066 Health Insurance Plan, 53901AZ1420066
-
Does Blue Portfolio HSA Bronze - Neighborhood Network Health Insurance Plan, 53901AZ1420066 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (53901AZ1420066) Health Insurance Plan, Variant (53901AZ1420066-01) have Out Of Country Coverage?
Does (53901AZ1420066) Health Insurance Plan, Variant (53901AZ1420066-01) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 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