BridgeSpan Standard Silver Plan - 34541UT0280006 Health Insurance Plan
BridgeSpan Health Company health insurance plan with the Plan ID 34541UT0280006. The plan is called BridgeSpan Standard Silver Plan.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.06% (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 5.94% 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 | 34541UT0280006 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | BridgeSpan Health Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 34541UT0280006-06 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| 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 Off Exchange Plan - 34541UT0280006-00 Standard On Exchange Plan - 34541UT0280006-01 Open to Indians below 300% FPL - 34541UT0280006-02 Open to Indians above 300% FPL - 34541UT0280006-03 73% AV Silver Plan - 34541UT0280006-04 |
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| Last Plan Update Date | Wed, 16 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of BridgeSpan Standard Silver Plan Health Insurance Plan, 34541UT0280006-06
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
NO | ||
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 25.00% |
100.00% |
| Autism Spectrum Disorders
|
YES | 25.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 25.00% |
100.00% |
| Chiropractic Care
|
NO | ||
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | 25.00% |
100.00% |
| Diabetes Education
|
YES | 25.00% |
100.00% |
| Dialysis
|
YES | 25.00% |
100.00% |
| Durable Medical Equipment
Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. |
YES | 25.00% |
100.00% |
| Emergency Room Services
Out of service area coverage is available. |
YES | 25.00% |
25.00% |
| Emergency Transportation/Ambulance
Out of service area coverage is available. |
YES | 25.00% |
25.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period One pair of lenses and one frame per year (contacts in lieu of glasses) |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | 25.00% |
100.00% |
| Generic Drugs
Limit: 30.0 Item(s) per Month insulin limit of? $28 er 30 days? $84 for 90 day supply |
YES | $0.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Benefit Period Habilitation services limited to 30 inpatient days per year and 20 outpatient visits per year. |
YES | $0.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | 25.00% |
100.00% |
| Hospice Services
Limit: 6.0 Months per 3 Years Requires Pre-authorization and Medical Case Management. |
YES | 25.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 25.00% |
100.00% |
| Inherited Metabolic Disorder - PKU
|
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
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). |
YES | 25.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Mental Health or Substance Use Disorder benefit consists of three potential categories: inpatient services which are covered subject to deductible/coinsurance; outpatient office and psychotherapy visits which are covered with a copayment; and all other outpatient services (such as laboratory and physical therapy) which are also covered subject to deductible/coinsurance. |
YES | $0.00 |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Item(s) per Month insulin limit of? $28 per 30 days? $84 for 90 day supply |
YES | $50.00 |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Benefit Period Combined rehabilitative limit for outpatient physical, occupational and speech therapies. 20 outpatient visits per year. Visit limit does not apply to Mental Health/Substance Abuse. |
YES | $0.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Item(s) per Month insulin limit of? $28 per 30 days? $84 for 90 day supply |
YES | $15.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 25.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $0.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Coverage limited only to artificial prosthetic eyes, when made necessary by loss from an injury or illness. |
YES | 25.00% |
100.00% |
| Radiation
|
YES | 25.00% |
100.00% |
| Reconstructive Surgery
Covers mastectomy in the treatment of cancer and reconstructive surgery after a mastectomy. |
YES | 25.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Benefit Period Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. Visit limit does not apply to Mental Health/Substance Abuse. |
YES | $0.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Benefit Period Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes. Visit limit does not apply to Mental Health/Substance Abuse. |
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 Benefit Period |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Visit(s) per Benefit Period 30 days per year for Inpatient Rehabilitation and Skilled Nursing Facility combined |
YES | 25.00% |
100.00% |
| Specialist Visit
|
YES | $10.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Item(s) per Month First fill allowed at a retail pharmacy. Insulin limit of $28 per 30 days, $84 for 90 day-supply |
YES | $150.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). |
YES | 25.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Mental Health or Substance Use Disorder benefit consists of three potential categories: inpatient services which are covered subject to deductible/coinsurance; outpatient office and psychotherapy visits which are covered with a copayment; and all other outpatient services (such as laboratory and physical therapy) which are also covered subject to deductible/coinsurance. |
YES | $0.00 |
100.00% |
| Transplant
|
YES | 25.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
Out of service area coverage is available. |
YES | $5.00 |
$5.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% |
100.00% |
BridgeSpan Standard Silver Plan Health Insurance Plan Variant 34541UT0280006-06 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.940590976666282 |
| 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 | 94% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | UTF006 |
| Formulary URL | URL |
| HIOS Product ID | 34541UT028 |
| Import Date | 2023-08-16 20:01:48 |
| 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? | No |
| Issuer ID | 34541 |
| Issuer Marketplace Marketing Name | BridgeSpan Health Company |
| 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 | No |
| Network ID | UTN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 34541UT0280006-06 |
| Plan Marketing Name | BridgeSpan Standard Silver Plan |
| Plan Type | HMO |
| Plan Variant Marketing Name | BridgeSpan Standard Silver Plan |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,800 |
| 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 | $200 |
| SBC Scenario, Having Diabetes, Copayment | $200 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $30 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | UTS001 |
| Source Name | SERFF |
| Plan ID | 34541UT0280006 |
| State Code | UT |
| 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 | $3600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $1800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $1,800 |
| 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 | No |
Copay & Coinsurance of BridgeSpan Standard Silver Plan Health Insurance Plan, 34541UT0280006
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about BridgeSpan Standard Silver Plan, 34541UT0280006 Health Insurance Plan, 34541UT0280006
-
Does BridgeSpan Standard Silver Plan Health Insurance Plan, 34541UT0280006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (34541UT0280006) Health Insurance Plan, Variant (34541UT0280006-06) have Out Of Country Coverage?
Does (34541UT0280006) Health Insurance Plan, Variant (34541UT0280006-06) have Out of Service Area Coverage?
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