New Hampshire health plan · 2025

Anthem Silver Preferred Blue PPO 6500/0%/9000 RxD · 57601NH0350019

Anthem Health Plans of New Hampshire offers this marketplace health insurance plan (Plan ID 57601NH0350019) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.

Metal level: Silver Plan type: PPO CSR: Standard Silver Off Exchange Plan Issuer: Anthem Health Plans of New Hampshire
Telehealth Data pending HSA eligible No Dental Child Vision Adult/Child
View issuer site

Issuer actuarial value: 69.05%. Expect to pay roughly 30.95% of covered costs out of pocket, based on issuer reporting.

CMS AV Calculator output: 70.77% (29.23% member share on average). Learn about AV methodology.

2025 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 02 Dec 2025 06:13 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$369 – $1574

Before subsidies

Estimate after subsidies

Deductible

N/A

N/A

See deductible details

Max out-of-pocket

$9,000

$18000 per group

Review MOOP rules

Office visits

Primary care $40.00
Specialist $80.00
HSA Not eligible

Drug tiers

Generic $25.00
Preferred brand $80.00 Copay after deductible

View formulary tiers

$536 / mo before subsidies

≈ $6434 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$1691 / mo before subsidies

≈ $20292 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$2041 / mo before subsidies

≈ $24498 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$1308 / mo before subsidies

≈ $15693 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits

Preventive Care/Screening/Immunization

No Charge

Emergency Room Services

$350.00 Copay after deductible

Durable Medical Equipment

0.00% Coinsurance after deductible

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Enrollment guidance

Stay on top of 2025 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in New Hampshire). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • Standard Silver Off Exchange Plan plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Top covered benefits

How this plan handles key care scenarios

Preventive Care/Screening/Immunization

No Charge

Emergency Room Services

$350.00 Copay after deductible

Durable Medical Equipment

0.00% Coinsurance after deductible

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 57601NH0350019
Coverage year 2025
State New Hampshire
Issuer Anthem Health Plans of New Hampshire
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 57601NH0350019-00
Available variants

Standard Off Exchange Plan · 57601NH0350019-00

Standard On Exchange Plan · 57601NH0350019-01
Last plan update Thu, 05 Dec 2024 00:00 GMT
Last HealthPorta import Tue, 02 Dec 2025 06:13 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).

All providers in New Hampshire 3
PCPs in New Hampshire N/A
Telehealth support Data pending
Nationwide providers 42
3 doctors statewide

Provider network(s)

Providers New Hampshire All US states
All 3 42
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists 2 24

Drug coverage overview

3,573 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Tier Covered drugs
TIER-FOUR 3,573
Prior authorization Drugs
Required 790
Not Required 2,783
Step therapy Drugs
Required 98
Not Required 3,475
Quantity limits Drugs
Has Limit 2,017
No Limit 1,556

Customer highlights

What stands out for members

  • Issuer: Anthem Health Plans of New Hampshire · Plan ID 57601NH0350019 · 2025 filing.
  • Disease management programs available: Asthma, Depression, Diabetes, Heart Disease, Pregnancy.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 57601NH0350019-00 (Standard Off Exchange Plan) currently displayed.
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Benefits

Covered services & limitations

Everyday care

Office visits, preventive care, labs, imaging, and home health.

Chiropractic Care

$40.00
Tier 1 in-network $40.00
Out-of-network 20.00% Coinsurance after deductible

Limit: 36.0 Visit(s) per Benefit Period

Limit is combined in network and out of network across all outpatient settings. Benefit limit does not apply to Osteopathic manipulative treatment. Cost share is driven by provider/setting. Cost share shown is for professional office-based services.

Exclusions: nan

Diabetes Education

$80.00
Tier 1 in-network $80.00
Out-of-network 20.00% Coinsurance after deductible

Cost share is driven by provider/setting. Cost share shown is for professional office-based services.

Exclusions: nan

Home Health Care Services

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Coverage excludes Private Duty nursing services.

Exclusions: nan

Laboratory Outpatient and Professional Services

No Charge
Tier 1 in-network No Charge
Out-of-network 20.00% Coinsurance after deductible

Cost share shown is for professional office-based services.

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

$40.00
Tier 1 in-network $40.00
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Preventive Care/Screening/Immunization

No Charge
Tier 1 in-network No Charge
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$40.00
Tier 1 in-network $40.00
Out-of-network 20.00% Coinsurance after deductible

PCP copay may be discounted depending upon provider selected.

Exclusions: nan

Rehabilitative Occupational and Rehabilitative Physical Therapy

$40.00
Tier 1 in-network $40.00
Out-of-network 20.00% Coinsurance after deductible

Limit: 60.0 Visit(s) per Benefit Period

Limit is 60 combined visits for rehabilitative Physical, Occupational, and Speech Therapy benefit. Limit is combined in network and out of network across all outpatient settings. Cost share is driven by provider/setting. Cost share shown is for professional office-based services.

Exclusions: nan

Rehabilitative Speech Therapy

$40.00
Tier 1 in-network $40.00
Out-of-network 20.00% Coinsurance after deductible

Limit: 60.0 Visit(s) per Benefit Period

Limit is 60 combined visits for rehabilitative Physical, Occupational, and Speech Therapy benefit. Limit is combined in network and out of network across all outpatient settings. Cost share is driven by provider/setting. Cost share shown is for professional office-based services.

Exclusions: nan

Specialist Visit

$80.00
Tier 1 in-network $80.00
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Urgent Care Centers or Facilities

$100.00
Tier 1 in-network $100.00
Out-of-network 20.00% Coinsurance after deductible

Costs may vary by site of service.

Exclusions: nan

X-rays and Diagnostic Imaging

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Cost share is driven by Provider setting.

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Dialysis

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Durable Medical Equipment

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Emergency Room Services

$350.00 Copay after deductible
Tier 1 in-network $350.00 Copay after deductible
Out-of-network $350.00 Copay after deductible

Emergency Room copay is waived if admitted to hospital.

Exclusions: nan

Emergency Transportation/Ambulance

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 0.00% Coinsurance after deductible

nan

Exclusions: nan

Hospice Services

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 20.00% Coinsurance after deductible

Cost share is driven by Provider setting.

Exclusions: nan

Inpatient Hospital Services (e.g., Hospital Stay)

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Limited to 100 days per benefit period for Inpatient Rehabilitation and Skilled Nursing Facility Services combined. Limit applies to Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined in network and out of network.

Exclusions: nan

Inpatient Physician and Surgical Services

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Limited to 100 days per benefit period for Inpatient Rehabilitation services. Limit applies to Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined in network and out of network.

Exclusions: nan

Mental/Behavioral Health Inpatient Services

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Mental/Behavioral Health Outpatient Services

$25.00
Tier 1 in-network $25.00
Out-of-network 20.00% Coinsurance after deductible

Cost share is driven by Provider setting.

Exclusions: nan

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

$500.00 Copay after deductible
Tier 1 in-network $500.00 Copay after deductible
Out-of-network 20.00% Coinsurance after deductible

Cost share is driven by Provider setting.

Exclusions: nan

Outpatient Rehabilitation Services

$40.00
Tier 1 in-network $40.00
Out-of-network 20.00% Coinsurance after deductible

Limit: 60.0 Visit(s) per Benefit Period

Limited to 60 combined visits for Physical, Occupational, and Speech Therapy benefit. Limit is combined in network and out of network across all outpatient settings.Cost share is driven by provider/setting. Cost share shown is for professional office-based services.

Exclusions: nan

Outpatient Surgery Physician/Surgical Services

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Cost share is driven by Provider setting.

Exclusions: nan

Radiation

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Skilled Nursing Facility

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Limit: 100.0 Days per Benefit Period

Limited to 100 days per benefit period for Inpatient Rehabilitation services. Limit is combined in network and out of network.

Exclusions: nan

Substance Abuse Disorder Inpatient Services

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Substance Abuse Disorder Outpatient Services

$25.00
Tier 1 in-network $25.00
Out-of-network 20.00% Coinsurance after deductible

Cost share is driven by Provider setting.

Exclusions: nan

Transplant

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: Meals relative to transportation and lodging are excluded in and out of network.

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Hearing Aids

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Major Dental Care - Child

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Prenatal and Postnatal Care

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

In network preventive prenatal and postnatal services are covered at 100%.

Exclusions: nan

Routine Eye Exam for Children

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

Limit: 1.0 Visit(s) per Benefit Period

Limited reimbursement up to maximum allowable for all services. Eye exams are covered once per benefit period. Limit is combined in network and out of network.

Exclusions: nan

Well Baby Visits and Care

No Charge
Tier 1 in-network No Charge
Out-of-network 20.00% Coinsurance after deductible

Covered under preventive care.

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$25.00
Tier 1 in-network $25.00
Tier 2 in-network $35.00
Out-of-network 50.00%

Members can choose to receive a 90-day supply at retail pharmacies. When there is a copay, the copay is three times the standard retail copayment.

Exclusions: nan

Non-Preferred Brand Drugs

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Members can choose to receive a 90-day supply at retail pharmacies.

Exclusions: nan

Preferred Brand Drugs

$80.00 Copay after deductible
Tier 1 in-network $80.00 Copay after deductible
Tier 2 in-network $90.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Members can choose to receive a 90-day supply at retail pharmacies. When there is a copay, the copay is three times the standard retail copayment.

Exclusions: nan

Specialty Drugs

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

$500.00 Copay after deductible
Tier 1 in-network $500.00 Copay after deductible
Out-of-network 20.00% Coinsurance after deductible

Benefits are available for dental work that is Medically Necessary due to an accidental injury to sound natural teeth and gums when the course of treatment for the accidental injury is received or authorized within 3 months of the date of the injury. Cost share is driven by provider/setting.

Exclusions: nan

Basic Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Dental Check-Up for Children

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 30.00% Coinsurance after deductible

Limit: 2.0 Visit(s) per Benefit Period

nan

Exclusions: nan

Infusion Therapy

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Cost share is driven by Provider setting.

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Nutritional Counseling

$25.00
Tier 1 in-network $25.00
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Prosthetic Devices

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Routine Dental Services (Adult)

Coverage details pending

nan

Exclusions: nan

Weight Loss Programs

Coverage details pending

nan

Exclusions: nan

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

$500.00 Copay after deductible
Tier 1 in-network $500.00 Copay after deductible
Out-of-network 20.00% Coinsurance after deductible

Cost share is driven by Provider setting.

Exclusions: nan

Acupuncture

$40.00
Tier 1 in-network $40.00
Out-of-network 20.00% Coinsurance after deductible

Limit: 20.0 Visit(s) per Benefit Period

Limit is combined in network and out of network across all outpatient settings. Cost share is driven by provider/setting.

Exclusions: nan

Allergy Testing

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Cost share is driven by provider/setting. Cost share shown is for professional office-based services.

Exclusions: nan

Bariatric Surgery

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Benefits are available for bariatric surgery that is Medically Necessary for the treatment of diseases and ailments caused by or resulting from obesity or morbid obesity. Cost share is driven by Provider setting.

Exclusions: nan

Cosmetic Surgery

Coverage details pending

nan

Exclusions: nan

Eye Glasses for Children

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

Limit: 1.0 Item(s) per Benefit Period

Limited reimbursement up to maximum allowable for all services. Child frames and lenses or contact lenses are covered once per benefit period. Cost share is driven by provider/setting. Limit is combined in network and out of network.

Exclusions: nan

Gender Affirming Care

$500.00 Copay after deductible
Tier 1 in-network $500.00 Copay after deductible
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Habilitation Services

$40.00
Tier 1 in-network $40.00
Out-of-network 20.00% Coinsurance after deductible

Limit: 60.0 Visit(s) per Benefit Period

Limited to 60 combined visits for Physical, Occupational, and Speech Therapy benefit. Limit is combined in network and out of network across all outpatient settings.Cost share is driven by provider/setting. Cost share shown is for professional office-based services.

Exclusions: The plan excludes coverage of Maintenance Therapy, defined as a treatment given when no further gains are clear or likely to occur. Maintenance therapy includes care that helps you keep your current level of function and prevents loss of that function, but does not result in any change for the better.

Imaging (CT/PET Scans, MRIs)

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Cost share is driven by Provider setting.

Exclusions: nan

Infertility Treatment

$500.00 Copay after deductible
Tier 1 in-network $500.00 Copay after deductible
Out-of-network 20.00% Coinsurance after deductible

Covered Services include diagnostic tests to find the cause of infertility, such as diagnostic laparoscopy, endometrial biopsy, and semen analysis. Benefits also include services to treat the underlying medical conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). Cost share is driven by Provider setting.

Exclusions: nan

Long-Term/Custodial Nursing Home Care

Coverage details pending

nan

Exclusions: nan

Private-Duty Nursing

Coverage details pending

nan

Exclusions: nan

Reconstructive Surgery

0.00% Coinsurance after deductible
Tier 1 in-network 0.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Cost share is driven by Provider setting.

Exclusions: nan

Routine Eye Exam (Adult)

$20.00
Tier 1 in-network $20.00
Out-of-network 100.00%

Limit: 1.0 Visit(s) per Benefit Period

A limited reimbursement of $30 applies to Routine Eye Exams for Adults out of network. Limit is combined in network and out of network.

Exclusions: nan

Routine Foot Care

$80.00
Tier 1 in-network $80.00
Out-of-network 20.00% Coinsurance after deductible

Covered if medically necessary for illness or injury. Cost share is driven by provider/setting.

Exclusions: The following services are excluded from routine foot care. Cutting or removing corns and calluses, trimming nails, cleaning and preventive foot care including but not limited to; cleaning and soaking the feet, applying skin creams to care for skin tone and other services that are given when there is not an illness, injury or symptom involving the foot.

Treatment for Temporomandibular Joint Disorders

$500.00 Copay after deductible
Tier 1 in-network $500.00 Copay after deductible
Out-of-network 20.00% Coinsurance after deductible

Coverage includes TMJ surgery and limited non-surgical treatment. Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.

Exclusions: nan

Variant attributes

Anthem Silver Preferred Blue PPO 6500/0%/9000 RxD · Variant 57601NH0350019-00

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

Standard Silver Off Exchange Plan

HIOS Product ID

57601NH035

Metal Level

Silver

Plan ID (Standard Component ID with Variant)

57601NH0350019-00

Plan Marketing Name

Anthem Silver Preferred Blue PPO 6500/0%/9000 RxD

Plan Variant Marketing Name

Anthem Silver Preferred Blue PPO 6500/0%/9000 RxD

Issuer & service area

Issuer-provided metadata for this variant.

Issuer Actuarial Value

69.05%

Issuer ID

57601

Issuer Marketplace Marketing Name

Anthem Blue Cross and Blue Sheld

Market Coverage

SHOP (Small Group)

Multiple In Network Tiers

Yes

National Network

Yes

Network ID

NHN003

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

Service Area ID

NHS002

State Code

NH

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

0.707744979593596

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Drug EHB Deductible, In Network (Tier 1), Default Coinsurance

40.00%

Drug EHB Deductible, In Network (Tier 2), Default Coinsurance

40.00%

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

No

Medical Drug Maximum Out of Pocket Integrated

Yes

Medical EHB Deductible, In Network (Tier 1), Default Coinsurance

0.00%

Medical EHB Deductible, In Network (Tier 2), Default Coinsurance

0.00%

SBC Scenario, Having a Baby, Coinsurance

$0

SBC Scenario, Having a Baby, Copayment

$10

SBC Scenario, Having a Baby, Deductible

$6,500

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$2,200

SBC Scenario, Having Diabetes, Deductible

$250

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

$2,100

Specialty Drug Maximum Coinsurance

$650

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

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group

$18000 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person

$9000 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual

$9,000

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group

$18000 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person

$9000 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual

$9,000

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group

$36000 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person

$18000 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual

$18,000

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

NHF012

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$60

SBC Scenario, Having Diabetes, Limit

$20

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

0

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Drug EHB Deductible, Combined In/Out of Network, Family Per Group

$500 per group

Drug EHB Deductible, Combined In/Out of Network, Family Per Person

$250 per person

Drug EHB Deductible, Combined In/Out of Network, Individual

$250

Drug EHB Deductible, In Network (Tier 1), Family Per Group

per group not applicable

Drug EHB Deductible, In Network (Tier 1), Family Per Person

per person not applicable

Drug EHB Deductible, In Network (Tier 1), Individual

Not Applicable

Drug EHB Deductible, In Network (Tier 2), Family Per Group

per group not applicable

Drug EHB Deductible, In Network (Tier 2), Family Per Person

per person not applicable

Drug EHB Deductible, In Network (Tier 2), Individual

Not Applicable

Drug EHB Deductible, Out of Network, Family Per Group

per group not applicable

Drug EHB Deductible, Out of Network, Family Per Person

per person not applicable

Drug EHB Deductible, Out of Network, Individual

Not Applicable

Dental Only Plan

No

Disease Management Programs Offered

Asthma, Depression, Diabetes, Heart Disease, Pregnancy

First Tier Utilization

49%

HSA/HRA Employer Contribution

No

Import Date

2024-12-05 19:01:39

HSA Eligible

No

New/Existing Plan

Existing

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

No

Medical EHB Deductible, Combined In/Out of Network, Family Per Group

per group not applicable

Medical EHB Deductible, Combined In/Out of Network, Family Per Person

per person not applicable

Medical EHB Deductible, Combined In/Out of Network, Individual

Not Applicable

Medical EHB Deductible, In Network (Tier 1), Family Per Group

$13000 per group

Medical EHB Deductible, In Network (Tier 1), Family Per Person

$6500 per person

Medical EHB Deductible, In Network (Tier 1), Individual

$6,500

Medical EHB Deductible, In Network (Tier 2), Family Per Group

$13000 per group

Medical EHB Deductible, In Network (Tier 2), Family Per Person

$6500 per person

Medical EHB Deductible, In Network (Tier 2), Individual

$6,500

Medical EHB Deductible, Out of Network, Family Per Group

$26000 per group

Medical EHB Deductible, Out of Network, Family Per Person

$13000 per person

Medical EHB Deductible, Out of Network, Individual

$13,000

Plan Effective Date

2025-01-01

Plan Expiration Date

2025-12-31

Plan Type

PPO

QHP/Non QHP

Both

Second Tier Utilization

51%

Source Name

SERFF

Plan ID

57601NH0350019

Unique Plan Design

Yes

Wellness Program Offered

No

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in New Hampshire?

Anthem Silver Preferred Blue PPO 6500/0%/9000 RxD (57601NH0350019) is a Silver PPO from Anthem Health Plans of New Hampshire in New Hampshire for the 2025 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does Anthem Silver Preferred Blue PPO 6500/0%/9000 RxD support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is Anthem Silver Preferred Blue PPO 6500/0%/9000 RxD HSA-eligible and does it include dental or vision coverage?

It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.

Dental add-ons: Child.

Vision add-ons: Adult, Child.

Does Anthem Silver Preferred Blue PPO 6500/0%/9000 RxD support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Which disease management programs come with Anthem Silver Preferred Blue PPO 6500/0%/9000 RxD?

The issuer lists disease management resources for: Asthma, Depression, Diabetes, Heart Disease, Pregnancy.

Is there out-of-country coverage for Anthem Silver Preferred Blue PPO 6500/0%/9000 RxD?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: Full Access

Does Anthem Silver Preferred Blue PPO 6500/0%/9000 RxD cover care outside the service area?

Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: Standard Bluecard PPO Network

How do I enroll in or manage payments for Anthem Silver Preferred Blue PPO 6500/0%/9000 RxD?

Use the issuer portal https://file.anthem.com/SG2025/05516NHEENABS.pdf to pay premiums or start enrollment, then return to HealthPorta for benefit comparisons.

Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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