Blue Standardized Silver EPO - 46944AL0740001 Health Insurance Plan
Blue Cross and Blue Shield of Alabama health insurance plan with the Plan ID 46944AL0740001. The plan is called Blue Standardized Silver EPO.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.14% (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 5.86% 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 | 46944AL0740001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 46944AL0740001-06 | ||||||||||||||||||
| 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 - 46944AL0740001-00 Standard On Exchange Plan - 46944AL0740001-01 Open to Indians below 300% FPL - 46944AL0740001-02 Open to Indians above 300% FPL - 46944AL0740001-03 73% AV Silver Plan - 46944AL0740001-04 |
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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 Silver EPO Health Insurance Plan, 46944AL0740001-06
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 25.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Each member must have a referral from their designated primary care physician in the Blue High Performance Network for benefits to be covered. |
YES | 25.00% |
100.00% |
| 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 | 25.00% |
100.00% |
| Chemotherapy
|
YES | 25.00% |
100.00% |
| Chiropractic Care
Limit: 15.0 Visit(s) per Year |
YES | 25.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% |
100.00% |
| 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% |
100.00% |
| Dialysis
|
YES | 25.00% |
100.00% |
| Durable Medical Equipment
|
YES | 25.00% |
100.00% |
| Emergency Room Services
Physician charges may apply. |
YES | 25.00% |
25.00% |
| Emergency Transportation/Ambulance
|
YES | 25.00% |
25.00% |
| 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% |
25.00% |
| Gender Affirming Care
Exclusions: Excludes services deemed as cosmetic. |
YES | 25.00% |
100.00% |
| Generic Drugs
Up to a 90-day supply |
YES | $0.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Combined maximum visits for Occupational, Physical and Speech Therapy |
YES | $0.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
|
YES | 25.00% |
100.00% |
| Hospice Services
|
YES | 25.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% |
100.00% |
| Infertility Treatment
Exclusions: Excludes Assisted Reproductive Technology |
YES | $10.00 |
100.00% |
| Infusion Therapy
|
YES | 25.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% |
100.00% |
| 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% |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 25.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $0.00 |
100.00% |
| Non-Preferred Brand Drugs
Up to a 90-day supply |
YES | $50.00 |
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% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Each member must have a referral from their designated primary care physician in the Blue High Performance Network for benefits to be covered. |
YES | No Charge |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Combined maximum visits for Occupational, Physical and Speech Therapy |
YES | $0.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Each member must have a referral from their designated primary care physician in the Blue High Performance Network for benefits to be covered. |
YES | 25.00% |
100.00% |
| Preferred Brand Drugs
Up to a 90-day supply; Covered insulins limited to a $99 member cost share per 30-day supply |
YES | $15.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 25.00% |
100.00% |
| Preventive Care/Screening/Immunization
A referral is required if the service is not rendered by the member's designated primary care physician in the Blue High Performance Network, 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 physician in the Blue High Performance Network. |
YES | $0.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 25.00% |
100.00% |
| Radiation
|
YES | 25.00% |
100.00% |
| Reconstructive Surgery
Each member must have a referral from their designated primary care physician in the Blue High Performance Network for benefits to be covered. |
YES | 25.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Combined maximum visits for Occupational, Physical and Speech Therapy |
YES | $0.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Combined maximum visits for Occupational, Physical and Speech Therapy |
YES | $0.00 |
100.00% |
| 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% |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
|
NO | ||
| Specialist Visit
Each member must have a referral from their designated primary care physician in the Blue High Performance Network for benefits to be covered. |
YES | $10.00 |
100.00% |
| Specialty Drugs
Up to a 30-day supply |
YES | $150.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $0.00 |
100.00% |
| Transplant
Limited to Blue Distinction Centers for Transplant Network |
YES | 25.00% |
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 physician in the Blue High Performance Network for benefits to be covered. |
YES | 25.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $5.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
This plan requires each member to designate and use a primary care physician in the Blue High Performance Network. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% |
100.00% |
Blue Standardized Silver EPO Health Insurance Plan Variant 46944AL0740001-06 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.941406910405139 |
| 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 | 94% AV Level Silver 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 | ALF103 |
| Formulary URL | URL |
| HIOS Product ID | 46944AL074 |
| 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 | Silver |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | ALN003 |
| 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) | 46944AL0740001-06 |
| Plan Marketing Name | Blue Standardized Silver EPO |
| Plan Type | EPO |
| Plan Variant Marketing Name | Blue Standardized Silver EPO |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,000 |
| 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 | $70 |
| SBC Scenario, Having Diabetes, Copayment | $100 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $40 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ALS004 |
| Source Name | HIOS |
| Specialist Requiring a Referral | All specialists seen in an office setting, excluding OB/GYN, Urgent Care, and Behavioral Health. |
| Plan ID | 46944AL0740001 |
| 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 | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 | $4000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $2000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $2,000 |
| 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 Silver EPO Health Insurance Plan, 46944AL0740001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Standardized Silver EPO, 46944AL0740001 Health Insurance Plan, 46944AL0740001
-
Does Blue Standardized Silver EPO Health Insurance Plan, 46944AL0740001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (46944AL0740001) Health Insurance Plan, Variant (46944AL0740001-06) offer Disease Management Programs?
Does (46944AL0740001) Health Insurance Plan, Variant (46944AL0740001-06) have Out Of Country Coverage?
Does (46944AL0740001) Health Insurance Plan, Variant (46944AL0740001-06) have Out of Service Area Coverage?
Does (46944AL0740001) Health Insurance Plan, Variant (46944AL0740001-06) offer Disease Management Programs?
Does Blue Standardized Silver EPO Health Insurance Plan, Variant (46944AL0740001-06) offer Disease Management Programs for Asthma?
Does Blue Standardized Silver EPO Health Insurance Plan, Variant (46944AL0740001-06) offer Disease Management Programs for Heart disease?
Does Blue Standardized Silver EPO Health Insurance Plan, Variant (46944AL0740001-06) offer Disease Management Programs for Diabetes?
Does Blue Standardized Silver EPO Health Insurance Plan, Variant (46944AL0740001-06) 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