my Blue Access WV PPO Gold 1700 HSA - 31274WV0580002 Health Insurance Plan
Highmark Blue Cross Blue Shield West Virginia health insurance plan with the Plan ID 31274WV0580002. The plan is called my Blue Access WV PPO Gold 1700 HSA.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.97% (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 21.03% 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 | 31274WV0580002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | West Virginia | ||||||||||||||||||
| Health Insurance Issuer | Highmark Blue Cross Blue Shield West Virginia | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 31274WV0580002-00 | ||||||||||||||||||
| Provider Network(s) | NONPREFERRED IN-NETWORK PREFERRED | ||||||||||||||||||
| 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 - 31274WV0580002-00 Standard On Exchange Plan - 31274WV0580002-01 |
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| Last Plan Update Date | Tue, 13 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of my Blue Access WV PPO Gold 1700 HSA Health Insurance Plan, 31274WV0580002-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $20.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
Surgery determined to be Medically Necessary is covered. |
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Oral Evaluations (Exams), Prophylaxis (cleanings), Fluoride Treatments, Sealants, Consultations |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 30.0 Visit(s) per Benefit Period 30 visits per benefit period for other than chronic pain 20 visits per event for chronic pain (visit limits are combined for physical therapy, occupational therapy and spinal manipulations) |
YES | $20.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Clinical Trials
|
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
Limited to reconstruction to restore body function or malformation caused by disease, trauma, birth defects, growth defects, prior therapeutic processes or as a result of an act of family violence |
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care
|
YES | $450.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Dental Anesthesia
|
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 1.0 Exam(s) per 6 Months |
YES | No Charge |
100.00% |
| Diabetes Care Management
|
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | $175.00 Copay after deductible |
$175.00 Copay after deductible |
| Emergency Transportation/Ambulance
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge after deductible |
100.00% |
| Gender Affirming Care
|
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Generic Drugs
|
YES | No Charge after deductible |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Limit does not apply to Habilitative services for the treatment of a Mental Health or Substance Abuse diagnosis. |
YES | $20.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period The following are Covered Services when you are Homebound and receive them from a Hospital or a Home Health Care Agency: Intermittent Skilled Care rendered by a registered or licensed practical nurse or nurse-midwife; Physical therapy, occupational therapy or speech therapy; Medical and surgical supplies; Prescription Drugs; Oxygen and its administration; Medical social Services; Home health aide visits when you are also receiving Skilled Care or Therapy Services; Laboratory tests; Home infusion therapy. |
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Hospice Services
Life expectancy 6 months or less |
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance use disorder. |
YES | $175.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered depending on your group?s prescription drug program |
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Infusion Therapy
|
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $450.00 Copay per Stay after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance use disorder. |
YES | $20.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Radiographs (all x-rays), space maintainers, amalgam restorations (metal filings), resin based composite filings (white fillings), crowns, inlays, onlays, crown repair, endodontic therapy (root canals, etc.), other endodontic services, surgical periodontics, non-surgical periodontics, periodontal maintenance, prosthetics (complete or fixed partial dentures), adjustments and repair of prosthetics, other prosthetic services, implant services, simple extractions, surgical extractions, oral surgery, general anesthesia, nitrous oxide and/or IV sedation |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | $450.00 Copay per Stay after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
|
YES | $20.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Mental Health Other
|
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
|
YES | $150.00 Copay after deductible |
100.00% |
| Nutritional Counseling
|
YES | No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Medically Necessary Orthodontics, with prior approval and written plan of care |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $20.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $130.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
|
YES | $20.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | $130.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
|
YES | $30.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $20.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
Limit: 35.0 Visit(s) per Benefit Period |
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Prosthetic Devices
|
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
|
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
(a) only those that restore a body function or which were caused by disease, trauma, birth defects, growth defects, prior therapeutic processes; or (b) reconstructive Surgery following Covered Services for a mastectomy, including reconstruction of the other breast for the purpose of restoring symmetry; or (c) reconstructive or cosmetic Surgery necessary as a result of an act of family violence. |
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Benefit Period 30 Rehab and 30 Habilitative/benefit period for other than chronic pain. Limit: 20 Rehab and 20 Habilitative/event for chronic pain (limits combined for PT, OT and spinal manipulations). Limit does not apply to therapy services for mental health or substance use disorder. |
YES | $20.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
|
YES | $20.00 Copay after deductible |
50.00% Coinsurance after deductible |
| 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
|
YES | $450.00 Copay per Stay after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $20.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $450.00 Copay per Stay after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | $20.00 Copay after deductible |
50.00% Coinsurance after deductible |
| Transplant
|
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
Orthotics, splints and appliances are limited to one every 3 years |
YES | 20.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 use disorder. |
YES | $40.00 Copay after deductible |
$40.00 Copay after deductible |
| 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 use disorder. |
YES | $20.00 Copay after deductible |
50.00% Coinsurance after deductible |
my Blue Access WV PPO Gold 1700 HSA Health Insurance Plan Variant 31274WV0580002-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.789739948502277 |
| 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 | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.9989 |
| First Tier Utilization | 100% |
| Formulary ID | WVF004 |
| Formulary URL | URL |
| HIOS Product ID | 31274WV058 |
| Import Date | 2024-08-13 20:01:38 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | Yes |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 31274 |
| Issuer Marketplace Marketing Name | Highmark Blue Cross Blue Shield West Virginia |
| 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 | WVN001 |
| 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) | 31274WV0580002-00 |
| Plan Marketing Name | my Blue Access WV PPO Gold 1700 HSA |
| Plan Type | PPO |
| Plan Variant Marketing Name | my Blue Access WV PPO Gold 1700 HSA |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $700 |
| SBC Scenario, Having a Baby, Deductible | $1,700 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $100 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| SBC Scenario, Having Diabetes, Deductible | $1,700 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $60 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,700 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WVS001 |
| Source Name | SERFF |
| Specialty Drug Maximum Coinsurance | $1,000 |
| Plan ID | 31274WV0580002 |
| State Code | WV |
| 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 | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3400 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,700 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $6800 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $3400 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $3,400 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $11400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $5700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,700 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $22800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $11400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $11,400 |
| 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 WV PPO Gold 1700 HSA Health Insurance Plan, 31274WV0580002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about my Blue Access WV PPO Gold 1700 HSA, 31274WV0580002 Health Insurance Plan, 31274WV0580002
-
Does my Blue Access WV PPO Gold 1700 HSA Health Insurance Plan, 31274WV0580002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (31274WV0580002) Health Insurance Plan, Variant (31274WV0580002-00) offer Disease Management Programs?
Does (31274WV0580002) Health Insurance Plan, Variant (31274WV0580002-00) have Out Of Country Coverage?
Does (31274WV0580002) Health Insurance Plan, Variant (31274WV0580002-00) have Out of Service Area Coverage?
Does (31274WV0580002) Health Insurance Plan, Variant (31274WV0580002-00) offer Disease Management Programs?
Does my Blue Access WV PPO Gold 1700 HSA Health Insurance Plan, Variant (31274WV0580002-00) offer Disease Management Programs for Asthma?
Does my Blue Access WV PPO Gold 1700 HSA Health Insurance Plan, Variant (31274WV0580002-00) offer Disease Management Programs for Heart disease?
Does my Blue Access WV PPO Gold 1700 HSA Health Insurance Plan, Variant (31274WV0580002-00) offer Disease Management Programs for Depression?
Does my Blue Access WV PPO Gold 1700 HSA Health Insurance Plan, Variant (31274WV0580002-00) offer Disease Management Programs for Diabetes?
Does my Blue Access WV PPO Gold 1700 HSA Health Insurance Plan, Variant (31274WV0580002-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does my Blue Access WV PPO Gold 1700 HSA Health Insurance Plan, Variant (31274WV0580002-00) offer Disease Management Programs for Low back pain?
Does my Blue Access WV PPO Gold 1700 HSA Health Insurance Plan, Variant (31274WV0580002-00) offer Disease Management Programs for Pregnancy?
Does my Blue Access WV PPO Gold 1700 HSA Health Insurance Plan, Variant (31274WV0580002-00) offer Disease Management Programs for Weight loss programs?
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