my Direct Blue EPO Gold 1700 HSA - 33709PA0950004 Health Insurance Plan

Highmark Inc. health insurance plan with the Plan ID 33709PA0950004. The plan is called my Direct Blue EPO Gold 1700 HSA.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.14% (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 19.86% 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 33709PA0950004
Health Insurance Plan Year 2024
State Pennsylvania
Health Insurance Issuer Highmark Inc.
Health Insurance Plan Variant 33709PA0950004-01
Provider Network(s) ['PAN002']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 26 Nov 2024 06:27 GMT).

Providers Pennsylvania All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard On Exchange Plan - 33709PA0950004-01

Open to Indians below 300% FPL - 33709PA0950004-02

Open to Indians above 300% FPL - 33709PA0950004-03

Last Plan Update Date Mon, 12 Feb 2024 00:00 GMT
Last Import Date Tue, 26 Nov 2024 06:27 GMT

my Direct Blue EPO Gold 1700 HSA Health Insurance Plan Variant 33709PA0950004-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.801423205
Business Year 2024
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Gold On Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma
EHB Percent of Total Premium 100%
First Tier Utilization 100%
Formulary ID PAF004
HIOS Product ID 33709PA095
Import Date 2/12/2024
HSA Eligible Yes
IsItANewPlan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 33709
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 PAN002
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 The Plan covers only limited health care services received by a non-Blue Card (out-of-network) provider. Out-of-Network Covered Services include Emergency Care Services and Urgent Care Services. Any other Out-of-Network services will not be covered unless authorized by the Plan.
Plan Effective Date 1/1/2024
Plan ID (Standard Component ID with Variant) 33709PA0950004-01
Plan Marketing Name my Direct Blue EPO Gold 1700 HSA
Plan Type EPO
Plan Variant Marketing Name my Direct Blue EPO 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 PAS007
Source Name SERFF
Plan ID 33709PA0950004
State Code PA
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
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family per person not applicable | per group 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 $3400 per person | $3400 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,700
TEHBDedOutofNetFamily per person not applicable | per group 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 $5700 per person | $11400 per group
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 person not applicable | per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design No
Version Number 1
Wellness Program Offered Yes

Copay & Coinsurance of my Direct Blue EPO Gold 1700 HSA Health Insurance Plan, 33709PA0950004

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about my Direct Blue EPO Gold 1700 HSA, 33709PA0950004 Health Insurance Plan, 33709PA0950004

  • Does my Direct Blue EPO Gold 1700 HSA Health Insurance Plan, 33709PA0950004 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (33709PA0950004) Health Insurance Plan, Variant (33709PA0950004-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma

    Does (33709PA0950004) Health Insurance Plan, Variant (33709PA0950004-01) have Out Of Country Coverage?

    Yes. Details: 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.

    Does (33709PA0950004) Health Insurance Plan, Variant (33709PA0950004-01) have Out of Service Area Coverage?

    Yes. Details: The Plan covers only limited health care services received by a non-Blue Card (out-of-network) provider. Out-of-Network Covered Services include Emergency Care Services and Urgent Care Services. Any other Out-of-Network services will not be covered unless authorized by the Plan.

    Does (33709PA0950004) Health Insurance Plan, Variant (33709PA0950004-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Pain Management, Depression, Low Back Pain, Diabetes, Heart Disease, Asthma

    Does my Direct Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (33709PA0950004-01) offer Disease Management Programs for Asthma?

    Yes, the my Direct Blue EPO Gold 1700 HSA Health Insurance Plan Variant 33709PA0950004-01 offers Disease Management Program for Asthma.

    Does my Direct Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (33709PA0950004-01) offer Disease Management Programs for Heart disease?

    Yes, the my Direct Blue EPO Gold 1700 HSA Health Insurance Plan Variant 33709PA0950004-01 offers Disease Management Program for Heart disease.

    Does my Direct Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (33709PA0950004-01) offer Disease Management Programs for Depression?

    Yes, the my Direct Blue EPO Gold 1700 HSA Health Insurance Plan Variant 33709PA0950004-01 offers Disease Management Program for Depression.

    Does my Direct Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (33709PA0950004-01) offer Disease Management Programs for Diabetes?

    Yes, the my Direct Blue EPO Gold 1700 HSA Health Insurance Plan Variant 33709PA0950004-01 offers Disease Management Program for Diabetes.

    Does my Direct Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (33709PA0950004-01) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the my Direct Blue EPO Gold 1700 HSA Health Insurance Plan Variant 33709PA0950004-01 offers Disease Management Program for High blood pressure & high cholesterol.

    Does my Direct Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (33709PA0950004-01) offer Disease Management Programs for Low back pain?

    Yes, the my Direct Blue EPO Gold 1700 HSA Health Insurance Plan Variant 33709PA0950004-01 offers Disease Management Program for Low back pain.

    Does my Direct Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (33709PA0950004-01) offer Disease Management Programs for Pregnancy?

    Yes, the my Direct Blue EPO Gold 1700 HSA Health Insurance Plan Variant 33709PA0950004-01 offers Disease Management Program for Pregnancy.

    Does my Direct Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (33709PA0950004-01) offer Disease Management Programs for Weight loss programs?

    Yes, the my Direct Blue EPO Gold 1700 HSA Health Insurance Plan Variant 33709PA0950004-01 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Tue, 26 Nov 2024 06:27 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