Blue Portfolio HSA Gold - Statewide PPO Network - 53901AZ1490005 Health Insurance Plan
Blue Cross and Blue Shield of Arizona, Inc. health insurance plan with the Plan ID 53901AZ1490005. The plan is called Blue Portfolio HSA Gold - Statewide PPO Network.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.56% (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 21.44% 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 | 53901AZ1490005 | ||||||||||||||||||
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| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Arizona | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross and Blue Shield of Arizona, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 53901AZ1490005-01 | ||||||||||||||||||
| Provider Network(s) | STATEWIDEPPO | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 13 May 2025 06:05 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 53901AZ1490005-00 Standard On Exchange Plan - 53901AZ1490005-01 |
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| Last Plan Update Date | Tue, 17 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 13 May 2025 06:05 GMT |
Blue Portfolio HSA Gold Statewide PPO Health Insurance Plan Variant 53901AZ1490005-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.785639687037536 |
| 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 | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | AZF011 |
| Formulary URL | URL |
| HIOS Product ID | 53901AZ149 |
| Import Date | 2024-09-17 01:02:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| 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 ID | 53901 |
| Issuer Marketplace Marketing Name | Blue Cross Blue Shield of Arizona |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | AZN003 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergencies Only. Authorization required for non-emergent services. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergencies, Urgent Care and Authorized Follow-up Care. Urgent Care and Authorized Follow-up Care covered only through contracted providers. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 53901AZ1490005-01 |
| Plan Marketing Name | Blue Portfolio HSA Gold - Statewide PPO Network |
| Plan Type | PPO |
| Plan Variant Marketing Name | Blue Portfolio HSA Gold Statewide PPO |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,000 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $2,500 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $580 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $2,500 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $60 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | AZS013 |
| Source Name | HIOS |
| Plan ID | 53901AZ1490005 |
| State Code | AZ |
| 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 | $5000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $18000 per group |
| 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 | $9,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $9000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $4500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $4,500 |
| 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 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Blue Portfolio HSA Gold - Statewide PPO Network Health Insurance Plan, 53901AZ1490005
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Blue Portfolio HSA Gold - Statewide PPO Network, 53901AZ1490005 Health Insurance Plan, 53901AZ1490005
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Does Blue Portfolio HSA Gold - Statewide PPO Network Health Insurance Plan, 53901AZ1490005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (53901AZ1490005) Health Insurance Plan, Variant (53901AZ1490005-01) have Out Of Country Coverage?
Does (53901AZ1490005) Health Insurance Plan, Variant (53901AZ1490005-01) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 13 May 2025 06:05 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