my Blue Access PPO Gold 1700 HSA - 76168DE0710003 Health Insurance Plan
Highmark BCBSD Inc. health insurance plan with the Plan ID 76168DE0710003. The plan is called my Blue Access PPO Gold 1700 HSA.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 76168DE0710003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Delaware | ||||||||||||||||||
| Health Insurance Issuer | Highmark BCBSD Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 76168DE0710003-02 | ||||||||||||||||||
| Provider Network(s) | PREFERRED NONPREFERRED IN-NETWORK | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 76168DE0710003-00 Standard On Exchange Plan - 76168DE0710003-01 |
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| Last Plan Update Date | Wed, 14 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 10 Dec 2024 06:32 GMT |
Benefits of my Blue Access PPO Gold 1700 HSA Health Insurance Plan, 76168DE0710003-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | No Charge |
No Charge |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge |
No Charge |
| Bariatric Surgery
|
YES | No Charge |
No Charge |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | No Charge |
100.00% |
| Chemotherapy
|
YES | No Charge |
No Charge |
| Chiropractic Care
Limit: 30.0 Visit(s) per Benefit Period |
YES | No Charge |
No Charge |
| Clinical Trials
|
YES | No Charge |
No Charge |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge |
No Charge |
| Dental Check-Up for Children
Limit: 1.0 Exam(s) per 6 Months |
YES | No Charge |
100.00% |
| Diabetes Care Management
|
YES | No Charge |
No Charge |
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | No Charge |
No Charge |
| Durable Medical Equipment
|
YES | No Charge |
No Charge |
| Emergency Room Services
|
YES | No Charge |
No Charge |
| Emergency Transportation/Ambulance
|
YES | No Charge |
No Charge |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | No Charge |
No Charge |
| Generic Drugs
|
YES | No Charge |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period In parity with and comparable to outpatient rehabilitation services; 30 visits combined PT/OT and 30 visits speech therapy. |
YES | No Charge |
No Charge |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Limited to one hearing aid, per person, per ear, every three years |
YES | No Charge |
No Charge |
| Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period Aggregate with Visiting Nurse |
YES | No Charge |
No Charge |
| Hospice Services
|
YES | No Charge |
No Charge |
| Imaging (CT/PET Scans, MRIs)
Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance abuse. |
YES | No Charge |
No Charge |
| Infertility Treatment
|
YES | No Charge |
No Charge |
| Infusion Therapy
|
YES | No Charge |
No Charge |
| Inherited Metabolic Disorder - PKU
|
YES | No Charge |
No Charge |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge |
No Charge |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
No Charge |
| Laboratory Outpatient and Professional Services
Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance abuse. |
YES | No Charge |
No Charge |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | No Charge |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | No Charge |
No Charge |
| Mental/Behavioral Health Outpatient Services
|
YES | No Charge |
No Charge |
| Non-Preferred Brand Drugs
|
YES | No Charge |
100.00% |
| Nutritional Counseling
|
YES | No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | No Charge |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge |
No Charge |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge |
No Charge |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | No Charge |
No Charge |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge |
No Charge |
| Preferred Brand Drugs
|
YES | No Charge |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
No Charge |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | No Charge |
No Charge |
| Private-Duty Nursing
Limit: 240.0 Hours per Benefit Period Exclusions: Outpatient not covered |
YES | No Charge |
No Charge |
| Prosthetic Devices
|
YES | No Charge |
No Charge |
| Radiation
|
YES | No Charge |
No Charge |
| Reconstructive Surgery
|
YES | No Charge |
No Charge |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Benefit Period Limited to a combined total of thirty (30) Outpatient Visits for rehabilitative purposes per Benefit Period and a combined total of thirty (30) Outpatient Visits for habilitative purposes per Benefit Period. This limit does not apply when therapy services are prescribed for the treatment of Mental Illness or Substance Abuse. |
YES | No Charge |
No Charge |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Benefit Period Limited to thirty (30) Outpatient Visits for rehabilitative purposes per Benefit Period and thirty (30) Outpatient Visits for habilitative purposes per Benefit Period. This limit does not apply when therapy services are prescribed for the treatment of Mental Illness or Substance Abuse. |
YES | No Charge |
No Charge |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 120.0 Days per Benefit Period |
YES | No Charge |
No Charge |
| Specialist Visit
|
YES | No Charge |
No Charge |
| Specialty Drugs
|
YES | No Charge |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge |
No Charge |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge |
No Charge |
| Transplant
|
YES | No Charge |
No Charge |
| Treatment for Temporomandibular Joint Disorders
Exclusions: Limited to Services to Determine Initial Diagnosis. Exclude Treatment Coverage when TMJ or Related Diagnosis Is only Reason for Treatment |
YES | No Charge |
No Charge |
| Urgent Care Centers or Facilities
The copayment, if any, does not apply to urgent care services prescribed for the treatment of mental illness or substance abuse. |
YES | No Charge |
No Charge |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance abuse. |
YES | No Charge |
No Charge |
my Blue Access PPO Gold 1700 AIAN Zero Health Insurance Plan Variant 76168DE0710003-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1.0 |
| 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 | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.9988 |
| First Tier Utilization | 100% |
| Formulary ID | DEF004 |
| Formulary URL | URL |
| HIOS Product ID | 76168DE071 |
| Import Date | 2024-08-14 20:01:41 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | 0 |
| 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 | 76168 |
| Issuer Marketplace Marketing Name | Highmark Blue Cross Blue Shield Delaware |
| 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 | DEN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Coverage is provided through the Blue Cross Blue Shield Global Core when a Member requires Emergency Care Services or Urgent Care Services while traveling or living outside the United States. All Emergency Care Services and Urgent Care Services are covered in accordance within the Member's Agreement. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | If a member receives non-emergency medically necessary and appropriate care from an out-of-area Blue Card provider, benefits will be paid in accordance with the contract. If a member receives non-emergency care from a non-Blue Card provider, services will be covered at the lower, out-of-network level and the member will be financially responsible for the difference between the plan's payment and the full amount of the out-of-area provider's charge. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 76168DE0710003-02 |
| Plan Marketing Name | my Blue Access PPO Gold 1700 HSA |
| Plan Type | PPO |
| Plan Variant Marketing Name | my Blue Access PPO Gold 1700 AIAN Zero |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| 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 | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | DES001 |
| Source Name | SERFF |
| Plan ID | 76168DE0710003 |
| State Code | DE |
| 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 | $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 | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of my Blue Access PPO Gold 1700 HSA Health Insurance Plan, 76168DE0710003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about my Blue Access PPO Gold 1700 HSA, 76168DE0710003 Health Insurance Plan, 76168DE0710003
-
Does my Blue Access PPO Gold 1700 HSA Health Insurance Plan, 76168DE0710003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (76168DE0710003) Health Insurance Plan, Variant (76168DE0710003-02) offer Disease Management Programs?
Does (76168DE0710003) Health Insurance Plan, Variant (76168DE0710003-02) have Out Of Country Coverage?
Does (76168DE0710003) Health Insurance Plan, Variant (76168DE0710003-02) have Out of Service Area Coverage?
Does (76168DE0710003) Health Insurance Plan, Variant (76168DE0710003-02) offer Disease Management Programs?
Does my Blue Access PPO Gold 1700 AIAN Zero Health Insurance Plan, Variant (76168DE0710003-02) offer Disease Management Programs for Asthma?
Does my Blue Access PPO Gold 1700 AIAN Zero Health Insurance Plan, Variant (76168DE0710003-02) offer Disease Management Programs for Heart disease?
Does my Blue Access PPO Gold 1700 AIAN Zero Health Insurance Plan, Variant (76168DE0710003-02) offer Disease Management Programs for Diabetes?
Does my Blue Access PPO Gold 1700 AIAN Zero Health Insurance Plan, Variant (76168DE0710003-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does my Blue Access PPO Gold 1700 AIAN Zero Health Insurance Plan, Variant (76168DE0710003-02) offer Disease Management Programs for Pregnancy?
Does my Blue Access PPO Gold 1700 AIAN Zero Health Insurance Plan, Variant (76168DE0710003-02) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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