Silver 5000 - 22013UT2630003 Health Insurance Plan
Regence BlueCross BlueShield of Utah health insurance plan with the Plan ID 22013UT2630003. The plan is called Silver 5000.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 73.15% (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 26.85% 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 | 22013UT2630003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | Regence BlueCross BlueShield of Utah | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 22013UT2630003-04 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 26 Nov 2024 06:27 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 22013UT2630003-00 Standard On Exchange Plan - 22013UT2630003-01 Open to Indians below 300% FPL - 22013UT2630003-02 Open to Indians above 300% FPL - 22013UT2630003-03 73% AV Silver Plan - 22013UT2630003-04 |
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| Last Plan Update Date | Tue, 13 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 26 Nov 2024 06:27 GMT |
Benefits of Silver 5000 Health Insurance Plan, 22013UT2630003-04
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Services to treat injury of the natural teeth. Services must be provided within 12 months of the injury. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Autism Spectrum Disorders
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 10.0 Procedure(s) per Year Spinal manipulations |
YES | $20.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 2.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Diabetes Care Management
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Equipment that can withstand repeated use, is primarily used to serve a medical purpose, not useful in the absence of illness or injury and is appropriate for use in the enrollees home. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Out of service area coverage is available. |
YES | 10.00% Coinsurance after deductible |
10.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Out of service area coverage is available. |
YES | 10.00% Coinsurance after deductible |
10.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period One pair of lenses and one frame per year (contacts in lieu of glasses) |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
|
YES | $10.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Benefit Period Habilitation services limited to 30 inpatient days per year and 20 outpatient visits per year. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Limit: 14.0 Days per Lifetime Limit of 14 days applies to respite care only. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Inherited Metabolic Disorder - PKU
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Mental Health or Substance Use Disorder benefit consists of three potential categories: inpatient services which are covered subject to deductible/coinsurance; outpatient office and psychotherapy visits which are covered with a copayment; and all other outpatient services (such as laboratory and physical therapy) which are also covered subject to deductible/coinsurance. Virtual Care (Telehealth) Visit $10 Copay |
YES | $20.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $20.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Benefit Period Combined rehabilitative limit for outpatient physical, occupational and speech therapies. 20 outpatient visits per year. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
insulin limit of? $25 per 30 days? $75 for 90 day supply |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Virtual Care (Telehealth) Visit $10 Copay |
YES | $20.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Limited covered services. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Covers mastectomy in the treatment of cancer and reconstructive surgery after a mastectomy. |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Benefit Period Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Benefit Period Combined limit for PT, OT, and ST, including therapy for neurodevelopmental purposes |
YES | 10.00% 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
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Visit(s) per Benefit Period 30 days per year for Inpatient Rehabilitation and Skilled Nursing Facility combined |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Virtual Care (Telehealth) Visit $10 Copay |
YES | $60.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Item(s) per Month First fill allowed at a retail pharmacy. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). |
YES | 10.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Mental health conditions and substance use disorders are defined as mental disorders and substance related disorders included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Mental Health or Substance Use Disorder benefit consists of three potential categories: inpatient services which are covered subject to deductible/coinsurance; outpatient office and psychotherapy visits which are covered with a copayment; and all other outpatient services (such as laboratory and physical therapy) which are also covered subject to deductible/coinsurance. Virtual Care (Telehealth) Visit $10 Copay |
YES | $20.00 |
100.00% |
| Transplant
|
YES | 10.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
Out of service area coverage is available. |
YES | $60.00 |
$60.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 10.00% Coinsurance after deductible |
100.00% |
Silver 5000 Health Insurance Plan Variant 22013UT2630003-04 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.731507253449051 |
| 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 | 73% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Heart Disease, Depression, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 0.997 |
| First Tier Utilization | 100% |
| Formulary ID | UTF012 |
| Formulary URL | URL |
| HIOS Product ID | 22013UT263 |
| Import Date | 2024-08-13 20:01:38 |
| 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 | 22013 |
| Issuer Marketplace Marketing Name | Regence BlueCross BlueShield of Utah |
| 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 | UTN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 22013UT2630003-04 |
| Plan Marketing Name | Silver 5000 |
| Plan Type | EPO |
| Plan Variant Marketing Name | Silver 5000 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,500 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $4,100 |
| 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 | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | UTS001 |
| Source Name | SERFF |
| Plan ID | 22013UT2630003 |
| State Code | UT |
| 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 | 10.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $8200 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4100 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,100 |
| 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 | $14700 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7350 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,350 |
| 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 5000 Health Insurance Plan, 22013UT2630003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Silver 5000, 22013UT2630003 Health Insurance Plan, 22013UT2630003
-
Does Silver 5000 Health Insurance Plan, 22013UT2630003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (22013UT2630003) Health Insurance Plan, Variant (22013UT2630003-04) offer Disease Management Programs?
Does (22013UT2630003) Health Insurance Plan, Variant (22013UT2630003-04) have Out Of Country Coverage?
Does (22013UT2630003) Health Insurance Plan, Variant (22013UT2630003-04) have Out of Service Area Coverage?
Does (22013UT2630003) Health Insurance Plan, Variant (22013UT2630003-04) offer Disease Management Programs?
Does Silver 5000 Health Insurance Plan, Variant (22013UT2630003-04) offer Disease Management Programs for Heart disease?
Does Silver 5000 Health Insurance Plan, Variant (22013UT2630003-04) offer Disease Management Programs for Depression?
Does Silver 5000 Health Insurance Plan, Variant (22013UT2630003-04) offer Disease Management Programs for Low back pain?
Does Silver 5000 Health Insurance Plan, Variant (22013UT2630003-04) offer Disease Management Programs for Pregnancy?
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