VantageBlue 100/80 4000/8000 10/40/70/90/125 WOPD - 15287RI0250055 Health Insurance Plan
Blue Cross & Blue Shield of Rhode Island health insurance plan with the Plan ID 15287RI0250055. The plan is called VantageBlue 100/80 4000/8000 10/40/70/90/125 WOPD.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.41% (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 19.59% 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 | 15287RI0250055 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Rhode Island | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross & Blue Shield of Rhode Island | ||||||||||||||||||
| Health Insurance Plan Variant | 15287RI0250055-01 | ||||||||||||||||||
| Provider Network(s) | ['RIN001'] | ||||||||||||||||||
| 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 | |||||||||||||||||||
| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
VantageBlue 100/80 4000/8000 10/40/70/90/125 WOPD Health Insurance Plan Variant 15287RI0250055-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.804112725 |
| 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 |
| Disease Management Programs Offered | Pregnancy, High Blood Pressure & High Cholesterol, Weight Loss Programs, Low Back Pain, Diabetes, Heart Disease, Asthma |
| First Tier Utilization | 100% |
| Formulary ID | RIF003 |
| HIOS Product ID | 15287RI025 |
| HSA/HRA Employer Contribution | No |
| Import Date | 2/12/2024 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 15287 |
| Market Coverage | SHOP (Small Group) |
| 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 | RIN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Coverage for urgent or emergent care only as well as medically necessary services. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Coverage for urgent or emergent care only as well as medically necessary services. |
| Plan Effective Date | 1/1/2024 |
| Plan ID (Standard Component ID with Variant) | 15287RI0250055-01 |
| Plan Level Exclusions | This plan does not include coverage that is not medically necessary. This plan does not cover services rendered by excluded providers, naturopaths, homeopaths, providers or facilities who are not legally qualified or licensed, Christian Scientist Practitioners, Acupuncturists, or Massage Therapists. |
| Plan Marketing Name | VantageBlue 100/80 4000/8000 10/40/70/90/125 WOPD |
| Plan Type | PPO |
| Plan Variant Marketing Name | VantageBlue 100/80 4000/8000 10/40/70/90/125 WOPD |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $700 |
| SBC Scenario, Having a Baby, Deductible | $4,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $600 |
| SBC Scenario, Having Diabetes, Deductible | $500 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | RIS001 |
| Source Name | SERFF |
| Plan ID | 15287RI0250055 |
| State Code | RI |
| 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 | $4000 per person | $8000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,000 |
| TEHBDedOutofNetFamily | $8000 per person | $16000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $8,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $5000 per person | $10000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $19050 per person | $38100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $19,050 |
| Unique Plan Design | No |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of VantageBlue 100/80 4000/8000 10/40/70/90/125 WOPD Health Insurance Plan, 15287RI0250055
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about VantageBlue 100/80 4000/8000 10/40/70/90/125 WOPD, 15287RI0250055 Health Insurance Plan, 15287RI0250055
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Does VantageBlue 100/80 4000/8000 10/40/70/90/125 WOPD Health Insurance Plan, 15287RI0250055 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (15287RI0250055) Health Insurance Plan, Variant (15287RI0250055-01) offer Disease Management Programs?
Does (15287RI0250055) Health Insurance Plan, Variant (15287RI0250055-01) have Out Of Country Coverage?
Does (15287RI0250055) Health Insurance Plan, Variant (15287RI0250055-01) have Out of Service Area Coverage?
Does (15287RI0250055) Health Insurance Plan, Variant (15287RI0250055-01) offer Disease Management Programs?
Does VantageBlue 100/80 4000/8000 10/40/70/90/125 WOPD Health Insurance Plan, Variant (15287RI0250055-01) offer Disease Management Programs for Asthma?
Does VantageBlue 100/80 4000/8000 10/40/70/90/125 WOPD Health Insurance Plan, Variant (15287RI0250055-01) offer Disease Management Programs for Heart disease?
Does VantageBlue 100/80 4000/8000 10/40/70/90/125 WOPD Health Insurance Plan, Variant (15287RI0250055-01) offer Disease Management Programs for Diabetes?
Does VantageBlue 100/80 4000/8000 10/40/70/90/125 WOPD Health Insurance Plan, Variant (15287RI0250055-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does VantageBlue 100/80 4000/8000 10/40/70/90/125 WOPD Health Insurance Plan, Variant (15287RI0250055-01) offer Disease Management Programs for Low back pain?
Does VantageBlue 100/80 4000/8000 10/40/70/90/125 WOPD Health Insurance Plan, Variant (15287RI0250055-01) offer Disease Management Programs for Pregnancy?
Does VantageBlue 100/80 4000/8000 10/40/70/90/125 WOPD Health Insurance Plan, Variant (15287RI0250055-01) offer Disease Management Programs for Weight loss programs?
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