Premera Blue Cross Preferred Bronze HSA EPO 6400 - 49831WA1930002 Health Insurance Plan
Premera Blue Cross health insurance plan with the Plan ID 49831WA1930002. The plan is called Premera Blue Cross Preferred Bronze HSA EPO 6400.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.74% (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 35.26% 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 | 49831WA1930002 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Washington | ||||||||||||||||||
| Health Insurance Issuer | Premera Blue Cross | ||||||||||||||||||
| Health Insurance Plan Variant | 49831WA1930002-03 | ||||||||||||||||||
| Provider Network(s) | ['WAN001'] | ||||||||||||||||||
| 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 - 49831WA1930002-01 |
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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 |
Premera Blue Cross Preferred Bronze NQ EPO 6400 Health Insurance Plan Variant 49831WA1930002-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.647442892 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 99% |
| First Tier Utilization | 100% |
| Formulary ID | WAF004 |
| HIOS Product ID | 49831WA193 |
| Import Date | 2/12/2024 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 49831 |
| 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 | No |
| Network ID | WAN001 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Emergency Services only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Premera Members have access to the Individual Signature network of providers when outside the Service Area. Our Service Area is Franklin, Grays Harbor, King, Kitsap, Pacific, Pierce, Spokane, and Yakima counties in Washington. Benefits are not provided for out-of network providers. |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 49831WA1930002-03 |
| Plan Marketing Name | Premera Blue Cross Preferred Bronze HSA EPO 6400 |
| Plan Type | EPO |
| Plan Variant Marketing Name | Premera Blue Cross Preferred Bronze NQ EPO 6400 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $800 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $6,400 |
| 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 | WAS003 |
| Source Name | SERFF |
| Plan ID | 49831WA1930002 |
| 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 | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $6400 per person | $12800 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,400 |
| 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 | $7200 per person | $14400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,200 |
| 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 | No |
Copay & Coinsurance of Premera Blue Cross Preferred Bronze HSA EPO 6400 Health Insurance Plan, 49831WA1930002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Premera Blue Cross Preferred Bronze HSA EPO 6400, 49831WA1930002 Health Insurance Plan, 49831WA1930002
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Does Premera Blue Cross Preferred Bronze HSA EPO 6400 Health Insurance Plan, 49831WA1930002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (49831WA1930002) Health Insurance Plan, Variant (49831WA1930002-03) offer Disease Management Programs?
Does (49831WA1930002) Health Insurance Plan, Variant (49831WA1930002-03) have Out Of Country Coverage?
Does (49831WA1930002) Health Insurance Plan, Variant (49831WA1930002-03) have Out of Service Area Coverage?
Does (49831WA1930002) Health Insurance Plan, Variant (49831WA1930002-03) offer Disease Management Programs?
Does Premera Blue Cross Preferred Bronze NQ EPO 6400 Health Insurance Plan, Variant (49831WA1930002-03) offer Disease Management Programs for Asthma?
Does Premera Blue Cross Preferred Bronze NQ EPO 6400 Health Insurance Plan, Variant (49831WA1930002-03) offer Disease Management Programs for Heart disease?
Does Premera Blue Cross Preferred Bronze NQ EPO 6400 Health Insurance Plan, Variant (49831WA1930002-03) offer Disease Management Programs for Diabetes?
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