Anthem Gold Preferred Blue PPO 2000 20 4350 w HSA - 57601NH0350006 Health Insurance Plan
Anthem Health Plans of NH(Anthem BCBS) health insurance plan with the Plan ID 57601NH0350006. The plan is called Anthem Gold Preferred Blue PPO 2000 20 4350 w HSA.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 77.50% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 22.50% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 77.35% (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 22.65% 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 | 57601NH0350006 | ||||||||||||||||||
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| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | New Hampshire | ||||||||||||||||||
| Health Insurance Issuer | Anthem Health Plans of NH(Anthem BCBS) | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 57601NH0350006-00 | ||||||||||||||||||
| Provider Network(s) | ['NHN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Mon, 04 Apr 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Anthem Gold Preferred Blue PPO 2000 20 4350 w HAS Health Insurance Plan Variant 57601NH0350006-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.773456858 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2022 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pregnancy |
| First Tier Utilization | 52% |
| Formulary ID | NHF003 |
| Formulary URL | URL |
| HIOS Product ID | 57601NH035 |
| HSA/HRA Employer Contribution | No |
| Import Date | 4/4/2022 20:01 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | Yes |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 77.50% |
| Issuer ID | 57601 |
| Issuer Marketplace Marketing Name | Anthem Blue Cross and Blue Sheld |
| 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 | Yes |
| National Network | Yes |
| Network ID | NHN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Full Access |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Standard Bluecard PPO Network |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 57601NH0350006-00 |
| Plan Marketing Name | Anthem Gold Preferred Blue PPO 2000 20 4350 w HSA |
| Plan Type | PPO |
| Plan Variant Marketing Name | Anthem Gold Preferred Blue PPO 2000 20 4350 w HAS |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,900 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $2,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,500 |
| SBC Scenario, Having Diabetes, Deductible | $2,000 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $30 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 48% |
| Service Area ID | NHS002 |
| Source Name | SERFF |
| Specialty Drug Maximum Coinsurance | $650 |
| Plan ID | 57601NH0350006 |
| State Code | NH |
| 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 | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $4000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $4000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $4000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $2,000 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $8000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $8000 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $4,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $8700 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $4,350 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $8700 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $4,350 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $17400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $8,700 |
| Unique Plan Design | Yes |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Anthem Gold Preferred Blue PPO 2000 20 4350 w HSA Health Insurance Plan, 57601NH0350006
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Anthem Gold Preferred Blue PPO 2000 20 4350 w HSA, 57601NH0350006 Health Insurance Plan, 57601NH0350006
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Does Anthem Gold Preferred Blue PPO 2000 20 4350 w HSA Health Insurance Plan, 57601NH0350006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (57601NH0350006) Health Insurance Plan, Variant (57601NH0350006-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy
Does (57601NH0350006) Health Insurance Plan, Variant (57601NH0350006-00) have Out Of Country Coverage?
Yes. Details: Full Access
Does (57601NH0350006) Health Insurance Plan, Variant (57601NH0350006-00) have Out of Service Area Coverage?
Yes. Details: Standard Bluecard PPO Network
Does (57601NH0350006) Health Insurance Plan, Variant (57601NH0350006-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy
Does Anthem Gold Preferred Blue PPO 2000 20 4350 w HAS Health Insurance Plan, Variant (57601NH0350006-00) offer Disease Management Programs for Asthma?
Yes, the Anthem Gold Preferred Blue PPO 2000 20 4350 w HAS Health Insurance Plan Variant
57601NH0350006-00 offers Disease
Management Program for Asthma.
Does Anthem Gold Preferred Blue PPO 2000 20 4350 w HAS Health Insurance Plan, Variant (57601NH0350006-00) offer Disease Management Programs for Heart disease?
Yes, the Anthem Gold Preferred Blue PPO 2000 20 4350 w HAS Health Insurance Plan Variant
57601NH0350006-00 offers Disease
Management Program for Heart disease.
Does Anthem Gold Preferred Blue PPO 2000 20 4350 w HAS Health Insurance Plan, Variant (57601NH0350006-00) offer Disease Management Programs for Depression?
Yes, the Anthem Gold Preferred Blue PPO 2000 20 4350 w HAS Health Insurance Plan Variant
57601NH0350006-00 offers Disease
Management Program for Depression.
Does Anthem Gold Preferred Blue PPO 2000 20 4350 w HAS Health Insurance Plan, Variant (57601NH0350006-00) offer Disease Management Programs for Diabetes?
Yes, the Anthem Gold Preferred Blue PPO 2000 20 4350 w HAS Health Insurance Plan Variant
57601NH0350006-00 offers Disease
Management Program for Diabetes.
Does Anthem Gold Preferred Blue PPO 2000 20 4350 w HAS Health Insurance Plan, Variant (57601NH0350006-00) offer Disease Management Programs for Pregnancy?
Yes, the Anthem Gold Preferred Blue PPO 2000 20 4350 w HAS Health Insurance Plan Variant
57601NH0350006-00 offers Disease
Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Tue, 30 Apr 2024 06:06 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