IND Destination 65, Gold, NS, OON, POS, Dep25, Pediatric Dental - 49526NY0650031 Health Insurance Plan
Highmark BlueCross BlueShield of Western New York health insurance plan with the Plan ID 49526NY0650031. The plan is called IND Destination 65, Gold, NS, OON, POS, Dep25, Pediatric Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 80.79% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.21% 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 84.18% (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 15.82% 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 | 49526NY0650031 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | Highmark BlueCross BlueShield of Western New York | ||||||||||||||||||
| Health Insurance Plan Variant | 49526NY0650031-01 | ||||||||||||||||||
| Provider Network(s) | ['NYN001'] | ||||||||||||||||||
| 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 - 49526NY0650031-01 |
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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 |
IND Destination 65, Gold, NS, OON, POS, Dep25, Pediatric Dental Health Insurance Plan Variant 49526NY0650031-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.841803318 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| 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 | Low Back Pain, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 99% |
| First Tier Utilization | 100% |
| Formulary ID | NYF010 |
| HIOS Product ID | 49526NY065 |
| 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 | 80.79% |
| Issuer ID | 49526 |
| 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 | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family | $10000 per person | $20000 per group |
| Medical EHB Deductible, Out of Network, Individual | $10,000 |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | NYN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Out of Service Area providers available at a higher cost share |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 49526NY0650031-01 |
| Plan Marketing Name | IND Destination 65, Gold, NS, OON, POS, Dep25, Pediatric Dental |
| Plan Type | POS |
| Plan Variant Marketing Name | IND Destination 65, Gold, NS, OON, POS, Dep25, Pediatric Dental |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,800 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $400 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,000 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NYS001 |
| Source Name | SERFF |
| Specialty Drug Maximum Coinsurance | $750 |
| Plan ID | 49526NY0650031 |
| State Code | NY |
| 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 | $9450 per person | $18900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,450 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $20000 per person | $40000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $20,000 |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of IND Destination 65, Gold, NS, OON, POS, Dep25, Pediatric Dental Health Insurance Plan, 49526NY0650031
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about IND Destination 65, Gold, NS, OON, POS, Dep25, Pediatric Dental, 49526NY0650031 Health Insurance Plan, 49526NY0650031
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Does IND Destination 65, Gold, NS, OON, POS, Dep25, Pediatric Dental Health Insurance Plan, 49526NY0650031 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (49526NY0650031) Health Insurance Plan, Variant (49526NY0650031-01) offer Disease Management Programs?
Does (49526NY0650031) Health Insurance Plan, Variant (49526NY0650031-01) have Out Of Country Coverage?
Does (49526NY0650031) Health Insurance Plan, Variant (49526NY0650031-01) have Out of Service Area Coverage?
Does (49526NY0650031) Health Insurance Plan, Variant (49526NY0650031-01) offer Disease Management Programs?
Does IND Destination 65, Gold, NS, OON, POS, Dep25, Pediatric Dental Health Insurance Plan, Variant (49526NY0650031-01) offer Disease Management Programs for Asthma?
Does IND Destination 65, Gold, NS, OON, POS, Dep25, Pediatric Dental Health Insurance Plan, Variant (49526NY0650031-01) offer Disease Management Programs for Heart disease?
Does IND Destination 65, Gold, NS, OON, POS, Dep25, Pediatric Dental Health Insurance Plan, Variant (49526NY0650031-01) offer Disease Management Programs for Diabetes?
Does IND Destination 65, Gold, NS, OON, POS, Dep25, Pediatric Dental Health Insurance Plan, Variant (49526NY0650031-01) offer Disease Management Programs for Low back pain?
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