Silver 4500 Legacy - 77969OR5280015 Health Insurance Plan
Regence BlueCross BlueShield of Oregon health insurance plan with the Plan ID 77969OR5280015. The plan is called Silver 4500 Legacy.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.14% (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 29.86% 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 | 77969OR5280015 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Oregon | ||||||||||||||||||
| Health Insurance Issuer | Regence BlueCross BlueShield of Oregon | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 77969OR5280015-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| 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 Off Exchange Plan - 77969OR5280015-00 Standard On Exchange Plan - 77969OR5280015-01 Open to Indians below 300% FPL - 77969OR5280015-02 Open to Indians above 300% FPL - 77969OR5280015-03 73% AV Silver Plan - 77969OR5280015-04 |
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| Last Plan Update Date | Fri, 06 Oct 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Silver 4500 Legacy Health Insurance Plan, 77969OR5280015-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | No Charge |
100.00% |
| Accidental Dental
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Acupuncture
Limit: 12.0 Visit(s) per Year |
YES | $20.00 |
100.00% |
| Allergy Testing
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | 20.00% |
100.00% |
| Chemotherapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year |
YES | $20.00 |
100.00% |
| Cosmetic Surgery
one attempt to correct a scar or defect that resulted from an accidental injury or treatment for an accidental injury or one attempt to correct a scar or defect on the head or neck that resulted from a surgery (more than one attempt is covered if medically necessary) |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
YES | 0.00% |
100.00% |
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Hardware to correct visual defect due to severe medical or surgical problem such as stroke, neurological disease, trauma or eye surgery other than refractive procedures limited to one pair of glasses (frames and lenses) or contact lenses per calendar year. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Out of service area coverage is available |
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Out of service area coverage is available |
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year One pair of lenses and one frame per year (contacts in lieu of glasses) |
YES | No Charge |
100.00% |
| Gender Affirming Care
Information about gender affirming care can be found in plan documents. |
YES | 100.00% | |
| Generic Drugs
Insulin: $85 max out of pocket for 30 day supply prior to deductible |
YES | $10.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Visit limit does not apply to treatment of mental health conditions. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Hearing assistance coverage complies with state and federal law |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Respite care - max of 5 consecutive days; lifetime max of 30 days |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | 50.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $20.00 |
100.00% |
| Non-Preferred Brand Drugs
Insulin: $85 max out of pocket for 30 day supply prior to deductible |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | 50.00% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $20.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Visit limit does not apply to treatment of mental health conditions. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Insulin: $85 max out of pocket for 30 day supply prior to deductible |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $20.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Limit combined with Occupational, Physical, and Speech therapy. Visit limit does not apply to Mental Health/Substance Abuse. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Limit combined with Occupational, Physical, and Speech therapy. Visit limit does not apply to Mental Health/Substance Abuse. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
Covered when medically necessary. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $85.00 |
100.00% |
| Specialty Drugs
Insulin: $85 max out of pocket for 30 day supply prior to deductible |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $20.00 |
100.00% |
| Telehealth-Primary Care Visit
|
YES | $10.00 |
100.00% |
| Telehealth-Specialist Visit
|
YES | $85.00 |
100.00% |
| Transplant
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
Out of service area coverage is available |
YES | $85.00 |
$85.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 30.00% Coinsurance after deductible |
100.00% |
Silver 4500 Legacy Health Insurance Plan Variant 77969OR5280015-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.701433335221307 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 0.996 |
| First Tier Utilization | 100% |
| Formulary ID | ORF013 |
| Formulary URL | URL |
| HIOS Product ID | 77969OR528 |
| Import Date | 2023-10-06 20:01:50 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| 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 | 77969 |
| Issuer Marketplace Marketing Name | Regence BlueCross BlueShield of Oregon |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | ORN002 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 77969OR5280015-00 |
| Plan Marketing Name | Silver 4500 Legacy |
| Plan Type | EPO |
| Plan Variant Marketing Name | Silver 4500 Legacy |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,300 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $4,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $900 |
| SBC Scenario, Having Diabetes, Copayment | $400 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ORS002 |
| Source Name | SERFF |
| Plan ID | 77969OR5280015 |
| State Code | OR |
| 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 | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $9000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person 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 Per Group | $18900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9450 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,450 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Silver 4500 Legacy Health Insurance Plan, 77969OR5280015
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Silver 4500 Legacy, 77969OR5280015 Health Insurance Plan, 77969OR5280015
-
Does Silver 4500 Legacy Health Insurance Plan, 77969OR5280015 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (77969OR5280015) Health Insurance Plan, Variant (77969OR5280015-00) have Out Of Country Coverage?
Does (77969OR5280015) Health Insurance Plan, Variant (77969OR5280015-00) have Out of Service Area Coverage?
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