Blue Cross® Premier PPO Silver Extra - 15560MI1130001 Health Insurance Plan
Blue Cross Blue Shield of Michigan Mutual Insurance Company health insurance plan with the Plan ID 15560MI1130001. The plan is called Blue Cross® Premier PPO Silver Extra.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.86% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.14% 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 70.86% (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 29.14% 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 | 15560MI1130001 | ||||||||||||||||||
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| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross Blue Shield of Michigan Mutual Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 15560MI1130001-00 | ||||||||||||||||||
| Provider Network(s) | ['MIN006'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 15560MI1130001-00 Standard On Exchange Plan - 15560MI1130001-01 Open to Indians below 300% FPL - 15560MI1130001-02 Open to Indians above 300% FPL - 15560MI1130001-03 73% AV Silver Plan - 15560MI1130001-04 |
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| Last Plan Update Date | Wed, 18 Aug 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Blue Cross® Premier PPO Silver Extra Health Insurance Plan Variant 15560MI1130001-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.708578591 |
| 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 Silver Off Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | MIF056 |
| Formulary URL | URL |
| HIOS Product ID | 15560MI113 |
| Import Date | 8/18/2021 20:00 |
| 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 Actuarial Value | 70.86% |
| Issuer ID | 15560 |
| Issuer Marketplace Marketing Name | Blue Cross Blue Shield of Michigan Mutual Insurance Company |
| 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 | Yes |
| Network ID | MIN006 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Accidental injury and emergency only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Coverage outside the state of Michigan is out of network except for eligible urgent, emergency and accidental injuries services |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 15560MI1130001-00 |
| Plan Marketing Name | Blue Cross® Premier PPO Silver Extra |
| Plan Type | PPO |
| Plan Variant Marketing Name | Blue Cross® Premier PPO Silver Extra |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,600 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $4,800 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| 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 | MIS006 |
| Source Name | SERFF |
| Plan ID | 15560MI1130001 |
| State Code | MI |
| 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 | $9600 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4800 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,800 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $19200 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $9600 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $9,600 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17400 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 | $8,700 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $34800 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 | $17,400 |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Blue Cross® Premier PPO Silver Extra Health Insurance Plan, 15560MI1130001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Blue Cross® Premier PPO Silver Extra, 15560MI1130001 Health Insurance Plan, 15560MI1130001
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Does Blue Cross® Premier PPO Silver Extra Health Insurance Plan, 15560MI1130001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (15560MI1130001) Health Insurance Plan, Variant (15560MI1130001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does (15560MI1130001) Health Insurance Plan, Variant (15560MI1130001-00) have Out Of Country Coverage?
Yes. Details: Accidental injury and emergency only
Does (15560MI1130001) Health Insurance Plan, Variant (15560MI1130001-00) have Out of Service Area Coverage?
Yes. Details: Coverage outside the state of Michigan is out of network except for eligible urgent, emergency and accidental injuries services
Does (15560MI1130001) Health Insurance Plan, Variant (15560MI1130001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does Blue Cross® Premier PPO Silver Extra Health Insurance Plan, Variant (15560MI1130001-00) offer Disease Management Programs for Asthma?
Yes, the Blue Cross® Premier PPO Silver Extra Health Insurance Plan Variant
15560MI1130001-00 offers Disease
Management Program for Asthma.
Does Blue Cross® Premier PPO Silver Extra Health Insurance Plan, Variant (15560MI1130001-00) offer Disease Management Programs for Heart disease?
Yes, the Blue Cross® Premier PPO Silver Extra Health Insurance Plan Variant
15560MI1130001-00 offers Disease
Management Program for Heart disease.
Does Blue Cross® Premier PPO Silver Extra Health Insurance Plan, Variant (15560MI1130001-00) offer Disease Management Programs for Depression?
Yes, the Blue Cross® Premier PPO Silver Extra Health Insurance Plan Variant
15560MI1130001-00 offers Disease
Management Program for Depression.
Does Blue Cross® Premier PPO Silver Extra Health Insurance Plan, Variant (15560MI1130001-00) offer Disease Management Programs for Diabetes?
Yes, the Blue Cross® Premier PPO Silver Extra Health Insurance Plan Variant
15560MI1130001-00 offers Disease
Management Program for Diabetes.
Does Blue Cross® Premier PPO Silver Extra Health Insurance Plan, Variant (15560MI1130001-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Blue Cross® Premier PPO Silver Extra Health Insurance Plan Variant
15560MI1130001-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Blue Cross® Premier PPO Silver Extra Health Insurance Plan, Variant (15560MI1130001-00) offer Disease Management Programs for Low back pain?
Yes, the Blue Cross® Premier PPO Silver Extra Health Insurance Plan Variant
15560MI1130001-00 offers Disease
Management Program for Low back pain.
Does Blue Cross® Premier PPO Silver Extra Health Insurance Plan, Variant (15560MI1130001-00) offer Disease Management Programs for Pregnancy?
Yes, the Blue Cross® Premier PPO Silver Extra Health Insurance Plan Variant
15560MI1130001-00 offers Disease
Management Program for Pregnancy.
Does Blue Cross® Premier PPO Silver Extra Health Insurance Plan, Variant (15560MI1130001-00) offer Disease Management Programs for Weight loss programs?
Yes, the Blue Cross® Premier PPO Silver Extra Health Insurance Plan Variant
15560MI1130001-00 offers Disease
Management Program for Weight loss programs.
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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