Blue Standardized Gold - 46944AL0720001 Health Insurance Plan
Blue Cross and Blue Shield of Alabama health insurance plan with the Plan ID 46944AL0720001. The plan is called Blue Standardized Gold.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (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 21.94% 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 | 46944AL0720001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Alabama | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross and Blue Shield of Alabama | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 46944AL0720001-00 | ||||||||||||||||||
| Provider Network(s) | TIER-ONE | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 46944AL0720001-00 Standard On Exchange Plan - 46944AL0720001-01 |
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| Last Plan Update Date | Wed, 18 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Blue Standardized Gold Health Insurance Plan, 46944AL0720001-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
Each member must have a referral from their designated Primary Care Select Physician for benefits to be covered. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Benefits are available up to the end of the month in which the member turns 19. |
YES | 20.00% |
100.00% |
| Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 15.0 Visit(s) per Year |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year Benefits are available up to the end of the month in which the member turns 19. |
YES | No Charge |
100.00% |
| Diabetes Education
Limit: 10.0 Hours per Year Limited to 2 hours per year after initial 12-month educational period. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
Physician charges may apply. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance 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 Year Benefits are available up to the end of the month in which the member turns 19. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Gender Affirming Care
Exclusions: Excludes services deemed as cosmetic. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Generic Drugs
Up to a 90-day supply |
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Combined maximum visits for Occupational, Physical and Speech Therapy |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Hearing Aids
|
NO | ||
| Home Health Care Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Hospice Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
Exclusions: Excludes Assisted Reproductive Technology |
YES | $60.00 |
50.00% Coinsurance after deductible |
| Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Benefits are available up to the end of the month in which the member turns 19. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
Up to a 90-day supply |
YES | $60.00 |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Benefits are available up to the end of the month in which the member turns 19. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Each member must have a referral from their designated Primary Care Select Physician for benefits to be covered. |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Combined maximum visits for Occupational, Physical and Speech Therapy |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
Each member must have a referral for benefits to be covered. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
Up to a 90-day supply; Covered insulins limited to a $99 member cost share per 30-day supply |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
A referral is required if the service is not rendered by the member's designated Primary Care Select Physician, except for immunizations rendered by a pharmacy in the Pharmacy Vaccine Network. |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
This plan requires each member to designate and use a Primary Care Select Physician. |
YES | $30.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
Each member must have a referral from their designated Primary Care Select Physician for benefits to be covered. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Combined maximum visits for Occupational, Physical and Speech Therapy |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Combined maximum visits for Occupational, Physical and Speech Therapy |
YES | $30.00 |
50.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year Benefits are available up to the end of the month in which the member turns 19. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
|
NO | ||
| Specialist Visit
Each member must have a referral from their designated Primary Care Select Physician for benefits to be covered. |
YES | $60.00 |
50.00% Coinsurance after deductible |
| Specialty Drugs
Up to a 30-day supply |
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Transplant
Limited to Blue Distinction Centers for Transplant Network |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: Dental related services Limited to Phase I services. Each member must have a referral from their designated Primary Care Select Physician for benefits to be covered. |
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
|
YES | $45.00 |
50.00% Coinsurance after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
This plan requires each member to designate and use a Primary Care Select Physician. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Blue Standardized Gold Health Insurance Plan Variant 46944AL0720001-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.780602015767654 |
| 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 Gold Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | ALF101 |
| Formulary URL | URL |
| HIOS Product ID | 46944AL072 |
| Import Date | 2024-09-18 01:01:22 |
| 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? | Yes |
| Issuer ID | 46944 |
| Issuer Marketplace Marketing Name | Blue Cross and Blue Shield of Alabama |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | ALN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | If PPO provider is used, same benefits as PPO in country apply. If non-PPO provider is used, member is responsible for filing claims and out-of-network benefits would be applicable. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | If PPO provider is used, same benefits as PPO in service area apply. If non-PPO provider is used, member may be responsible for filing claims and out-of-network benefits would be applicable. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 46944AL0720001-00 |
| Plan Marketing Name | Blue Standardized Gold |
| Plan Type | PPO |
| Plan Variant Marketing Name | Blue Standardized Gold |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,800 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $300 |
| SBC Scenario, Having Diabetes, Limit | $40 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ALS001 |
| Source Name | HIOS |
| Specialist Requiring a Referral | All specialists seen in an office setting, excluding OB/GYN, Urgent Care, and Behavioral Health. |
| Plan ID | 46944AL0720001 |
| State Code | AL |
| 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 | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $6000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $3000 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $3,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| 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 | Yes |
Copay & Coinsurance of Blue Standardized Gold Health Insurance Plan, 46944AL0720001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Standardized Gold, 46944AL0720001 Health Insurance Plan, 46944AL0720001
-
Does Blue Standardized Gold Health Insurance Plan, 46944AL0720001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (46944AL0720001) Health Insurance Plan, Variant (46944AL0720001-00) offer Disease Management Programs?
Does (46944AL0720001) Health Insurance Plan, Variant (46944AL0720001-00) have Out Of Country Coverage?
Does (46944AL0720001) Health Insurance Plan, Variant (46944AL0720001-00) have Out of Service Area Coverage?
Does (46944AL0720001) Health Insurance Plan, Variant (46944AL0720001-00) offer Disease Management Programs?
Does Blue Standardized Gold Health Insurance Plan, Variant (46944AL0720001-00) offer Disease Management Programs for Asthma?
Does Blue Standardized Gold Health Insurance Plan, Variant (46944AL0720001-00) offer Disease Management Programs for Heart disease?
Does Blue Standardized Gold Health Insurance Plan, Variant (46944AL0720001-00) offer Disease Management Programs for Diabetes?
Does Blue Standardized Gold Health Insurance Plan, Variant (46944AL0720001-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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