Navigator Bronze HSA 7500 - 14057WA0060002 Health Insurance Plan
PacificSource Health Plans health insurance plan with the Plan ID 14057WA0060002. The plan is called Navigator Bronze HSA 7500.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.96% (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 36.04% 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 | 14057WA0060002 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Washington | ||||||||||||||||||
| Health Insurance Issuer | PacificSource Health Plans | ||||||||||||||||||
| Health Insurance Plan Variant | 14057WA0060002-01 | ||||||||||||||||||
| Provider Network(s) | ['WAN005'] | ||||||||||||||||||
| 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 - 14057WA0060002-01 |
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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 |
Navigator Bronze HSA 7500 Health Insurance Plan Variant 14057WA0060002-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.639604829 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Pregnancy, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 99% |
| First Tier Utilization | 100% |
| Formulary ID | WAF001 |
| HIOS Product ID | 14057WA006 |
| Import Date | 2/12/2024 |
| HSA Eligible | Yes |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 14057 |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | WAN005 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Care Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Out-of-Network Providers |
| Plan Effective Date | 1/1/2024 |
| Plan ID (Standard Component ID with Variant) | 14057WA0060002-01 |
| Plan Marketing Name | Navigator Bronze HSA 7500 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Navigator Bronze HSA 7500 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,400 |
| 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 | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WAS004 |
| Source Name | SERFF |
| Plan ID | 14057WA0060002 |
| State Code | WA |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $7500 per person | $15000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,500 |
| TEHBDedOutofNetFamily | $10000 per person | $20000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $10,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $7500 per person | $15000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $25000 per person | $50000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $25,000 |
| Unique Plan Design | No |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Navigator Bronze HSA 7500 Health Insurance Plan, 14057WA0060002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Navigator Bronze HSA 7500, 14057WA0060002 Health Insurance Plan, 14057WA0060002
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Does Navigator Bronze HSA 7500 Health Insurance Plan, 14057WA0060002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (14057WA0060002) Health Insurance Plan, Variant (14057WA0060002-01) offer Disease Management Programs?
Does (14057WA0060002) Health Insurance Plan, Variant (14057WA0060002-01) have Out Of Country Coverage?
Does (14057WA0060002) Health Insurance Plan, Variant (14057WA0060002-01) have Out of Service Area Coverage?
Does (14057WA0060002) Health Insurance Plan, Variant (14057WA0060002-01) offer Disease Management Programs?
Does Navigator Bronze HSA 7500 Health Insurance Plan, Variant (14057WA0060002-01) offer Disease Management Programs for Asthma?
Does Navigator Bronze HSA 7500 Health Insurance Plan, Variant (14057WA0060002-01) offer Disease Management Programs for Heart disease?
Does Navigator Bronze HSA 7500 Health Insurance Plan, Variant (14057WA0060002-01) offer Disease Management Programs for Diabetes?
Does Navigator Bronze HSA 7500 Health Insurance Plan, Variant (14057WA0060002-01) offer Disease Management Programs for Pregnancy?
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