Arizona health plan · 2025

Blue PPO PremierHealth Silver - Statewide PPO Network · 53901AZ1490002

Blue Cross Blue Shield of Arizona, Inc. offers this marketplace health insurance plan (Plan ID 53901AZ1490002) 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: 94% AV Level Silver Plan Issuer: Blue Cross Blue Shield of Arizona, Inc.
Telehealth Data pending HSA eligible No Dental Child Vision Child
Pay / Manage Plan View issuer site

CMS AV Calculator output: 94.92% (5.08% 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

$357 – $2073

Before subsidies

Estimate after subsidies

Deductible

$350

$700 per group

See deductible details

Max out-of-pocket

$750

$1500 per group

Review MOOP rules

Office visits

Primary care $5.00
Specialist $10.00
HSA Not eligible

Drug tiers

Generic $3.00
Preferred brand 20.00% Coinsurance after deductible

View formulary tiers

$724 / mo before subsidies

≈ $8691 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.

$2201 / mo before subsidies

≈ $26416 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.

$2688 / mo before subsidies

≈ $32258 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.

$1673 / mo before subsidies

≈ $20071 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, No Charge

Emergency Room Services

20.00% Coinsurance after deductible

Durable Medical Equipment

20.00% 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 Arizona). 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.
  • 94% AV Level Silver 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, No Charge

Emergency Room Services

20.00% Coinsurance after deductible

Durable Medical Equipment

20.00% 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 53901AZ1490002
Coverage year 2025
State Arizona
Issuer Blue Cross Blue Shield of Arizona, Inc.
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 53901AZ1490002-06
Available variants

Standard Off Exchange Plan · 53901AZ1490002-00

Standard On Exchange Plan · 53901AZ1490002-01

Open to Indians below 300% FPL · 53901AZ1490002-02

Open to Indians above 300% FPL · 53901AZ1490002-03

73% AV Silver Plan · 53901AZ1490002-04

87% AV Silver Plan · 53901AZ1490002-05

94% AV Silver Plan · 53901AZ1490002-06
Last plan update Tue, 17 Sep 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 Arizona N/A
PCPs in Arizona N/A
Telehealth support Data pending
Nationwide providers N/A
N/A doctors statewide N/A PCPs N/A OB/GYN

Provider network(s)

['AZN003']

Providers Arizona All US states
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A

Drug coverage overview

0 drugs tracked

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

Prior authorization Drugs
Required 0
Not Required 0
Step therapy Drugs
Required 0
Not Required 0
Quantity limits Drugs
Has Limit 0
No Limit 0

Customer highlights

What stands out for members

  • Issuer: Blue Cross Blue Shield of Arizona, Inc. · Plan ID 53901AZ1490002 · 2025 filing.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 53901AZ1490002-06 (94% AV Silver Plan ) currently displayed.
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Benefits

Covered services & limitations

Everyday care

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

Chiropractic Care

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00% Coinsurance after deductible

PPOs must cover medically necessary chiropractic visits.

Exclusions: nan

Diabetes Education

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Home Health Care Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 42.0 Visit(s) per Year

1. The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.; 2. The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.; 3.The home health agency delivering care must be certified within the state the care is received.; 4. The care that is being provided is not custodial care. A Home Health visit is considered to be up to four hours of services.

Exclusions: Excludes respite care, custodial care, private duty nursing.

Laboratory Outpatient and Professional Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Preventive Care/Screening/Immunization

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network 50.00% Coinsurance after deductible

Limit: 1.0 Exam(s) per Year

Benefits are limited to one (1) preventive physical exam per member, per calendar year, unless additional visits are necessary for the member to obtain all covered Preventive Services.

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$5.00
Tier 1 in-network $5.00
Out-of-network 50.00% Coinsurance after deductible

First 2 visits per person per calendar year are covered at no charge for in-network visits. Copay for additional PCP visits. 24/7 online doctor visits available with BlueCare Anywhere see SBC for more information.

Exclusions: PCP visits out-of-network within Arizona will be covered at the out-of-network cost. Free PCP virtual visits exclude visits with BlueCare Anywhere providers and only apply to telehealth visits with the members PCP.

Rehabilitative Occupational and Rehabilitative Physical Therapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 60.0 Visit(s) per Year

Visit limit is for multiple therapy types combined (PT, OT, ST, CT and Cardiac and Pulmonary Rehabilitative Visits).

Exclusions: Excludes group therapy, private duty nursing, and custodial care.

Rehabilitative Speech Therapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 60.0 Visit(s) per Year

Visit limit is for multiple therapy types combined (PT, OT, ST, CT and Cardiac and Pulmonary Rehabilitative Visits).

Exclusions: Excludes group therapy, private duty nursing, and custodial care.

Specialist Visit

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Urgent Care Centers or Facilities

$25.00
Tier 1 in-network $25.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

X-rays and Diagnostic Imaging

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Newborn benefits do not apply to the newly born child of an Eligible Dependent unless placement with the contract holder or covered spouse is confirmed through a court order or legal guardianship.

Exclusions: nan

Dialysis

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Durable Medical Equipment

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Benefits are limited to one (1) manual or electric (not hospital grade) breast pump and breast pump supplies per member, per calendar year. Benefits are limited to one (1) set of new and four (4) replacement sets of compression garments for the treatment of lymphedema per member, per calendar year. Benefits are limited to one (1) wig and one (1) hairpiece per member, per calendar year.

Exclusions: nan

Emergency Room Services

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

nan

Exclusions: nan

Emergency Transportation/Ambulance

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

nan

Exclusions: nan

Hospice Services

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network No Charge, No Charge

The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live.

Exclusions: Excludes respite care.

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

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Inpatient Physician and Surgical Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Mental/Behavioral Health Inpatient Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs.

Mental/Behavioral Health Outpatient Services

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00% Coinsurance after deductible

Counseling and psychiatric telehealth consultations available with BlueCare Anywhere - see SBC for more information.

Exclusions: Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs.

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

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Outpatient Rehabilitation Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 60.0 Visit(s) per Year

Short-term rehabilitative therapy includes services in an outpatient facility or physicians office that is part of a rehabilitation program. These services may include physical, speech, occupational, cardiac rehabilitation,cognitive and pulmonary rehabilitation therapy. Visit limit is for all therapy types combined.

Exclusions: Visit limit is separate from habilitation service limit. Excludes group therapy, private duty nursing, and custodial care.

Outpatient Surgery Physician/Surgical Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Radiation

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Skilled Nursing Facility

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 90.0 Days per Year

90 combined SNF and inpatient extended active rehabilitation days per calendar year.

Exclusions: nan

Substance Abuse Disorder Inpatient Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs.

Substance Abuse Disorder Outpatient Services

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs.

Transplant

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Travel & lodging expenses are limited to $10,000 per transplant. Travel and lodging are not covered if the Member is a donor. Organ transplant services include the recipient's medical, surgical and hospital services; inpatient immunosuppressive medications; and costs for organ procurement. Transplant services are covered only if they are required to perform human to human organ or tissue transplants, such as:1. Allogeneic bone marrow/stem cell;2. Autologous bone marrow/stem cell;3. Cornea;4. Heart;5. Heart/lung;6. Kidney;7. Kidney/pancreas;8. Liver;9. Lung;10. Pancreas;11. Small bowel/liver; or 12. Kidney/liver. Organ transplant coverage will apply only to non-experimental transplants for the specific diagnosis. Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary.

Exclusions: nan

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Out-of-network 60.00% Coinsurance after deductible

nan

Exclusions: nan

Hearing Aids

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 1.0 Item(s) per Benefit Period

Hearing aid devices limited to one per ear, per Calendar Year when determined to be medically necessary by the Medical Management Organization.

Exclusions: Excludes disposable hearing aids, ear molds, batteries or battery replacements for hearing aids other than cochlear implants.

Major Dental Care - Child

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Out-of-network 60.00% Coinsurance after deductible

nan

Exclusions: nan

Prenatal and Postnatal Care

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Routine Eye Exam for Children

No Charge
Tier 1 in-network No Charge
Out-of-network 50.00% Coinsurance after deductible

Limit: 1.0 Visit(s) per Year

Limit of 1 routine vision exam per calendar year.

Exclusions: nan

Well Baby Visits and Care

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network 50.00% Coinsurance after deductible

Well Child visits and immunizations are covered as recommended by the American Academy of Pediatrics.

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$3.00
Tier 1 in-network $3.00
Tier 2 in-network $5.00
Out-of-network 50.00% Coinsurance after deductible

Prescription drugs in Tier 1a:Low copays on 30-day supplies of common everyday prescriptions including select insulin. Find out if your prescriptions are on the BCBSAZ Tier1a Drug List at https://azblue.com/pharmacy-management/Tier1a-Drug-List.

Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.

Non-Preferred Brand Drugs

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.

Preferred Brand Drugs

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.

Specialty Drugs

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

nan

Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Benefits are payable for the services of a Physician, dentist, or dental surgeon, provided the services are rendered for treatment of an accidental injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident.

Exclusions: nan

Basic Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Dental Check-Up for Children

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network No Charge

Limit: 2.0 Visit(s) per Year

Limit of 2 dental check-ups & cleanings per calendar year.

Exclusions: nan

Infusion Therapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Infusion/IV Therapy in an Outpatient setting including, but not limited to: Inflixima/b (Remicade), Alefacept (Amevive), and Etanercept (Enbrel).

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Nutritional Counseling

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network 50.00% Coinsurance after deductible

Covered when dietary adjustment has a therapeutic role of a diagnosed chronic disease/condition, including but not limited to:1. Morbid obesity 2. Diabetes3. Cardiovascular disease 4. Hypertension 5. Kidney disease 6. Eating disorders 7. Gastrointestinal disorders 8. Food allergies 9. Hyperlipidemia

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 60.00% Coinsurance after deductible

nan

Exclusions: nan

Prosthetic Devices

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

The Plan covers the initial purchase and fitting of external prosthetic devices which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, injury, congenital defect, or alopecia as a result of chemotherapy, radiation therapy, and second or third degree burns. External prosthetic appliances shall include artificial arms and legs, wigs, hair pieces and terminal devices such as a hand or hook. Wigs and hair pieces are limited to one per Plan Year. Members must provide a valid prescription verifying diagnosis of alopecia as a result of chemotherapy, radiation therapy, second or third degree burns with a submitted claim for coverage. All other diagnosis are excluded. Replacement of artificial arms and legs and terminal devices are covered only if necessitated by normal anatomical growth or as a result of wear and tear.

Exclusions: Excludes biomechanical devices (external prosthetic device operated through or in conjunction with nerve conduction or other electrical impulses).

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

Coverage details pending

nan

Exclusions: nan

Acupuncture

Coverage details pending

nan

Exclusions: nan

Allergy Testing

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Bariatric Surgery

$250.00 Copay with deductible, 20.00% Coinsurance after deductible
Tier 1 in-network $250.00 Copay with deductible, 20.00% Coinsurance after deductible
Out-of-network $250.00 Copay with deductible, 50.00% Coinsurance after deductible

The following bariatric surgery procedures are covered: open roux-en-y gastric bypass (RYGBP), laparoscopic roux-en-y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), open biliopancreatic diversion with duodenal switch (BPD/DS), laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS), and laparoscopic sleeve gastrectomy (LSG) 1. The patient must have a body-mass index (BMI) greater than equal to 35.; 2. Have at least one co-morbidity related to obesity.; 3. Previously unsuccessful with medical treatment for obesity. The following medical information must be documented in the patient's medical record: Active participation within the last two years in one physiciansupervised weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of all of the following components: a. Weight; b. Current dietary program; c. Physical activity (e.g., exercise program); 4. In addition, the procedure must be performed at an approved BlueDistinction facility for bariatric surgery; 5. The member must be 18 years or older, or have reached full expected skeletal growth.

Exclusions: nan

Cosmetic Surgery

Coverage details pending

nan

Exclusions: nan

Eye Glasses for Children

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

Limit: 1.0 Item(s) per Year

Limit of 1 pair of glasses or contact lenses per calendar year.

Exclusions: nan

Gender Affirming Care

Coverage details pending

nan

Exclusions: nan

Habilitation Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 60.0 Visit(s) per Year

Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical, speech, occupational, cardiac, cognitive and pulmonary habilitation therapy for people with disabilities in a variety of inpatient and/or outpatient settings.

Exclusions: Visit limit is separate from outpatient rehabilitation service limit. Excludes group therapy, private duty nursing, and custodial care.

Imaging (CT/PET Scans, MRIs)

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Infertility Treatment

Coverage details pending

nan

Exclusions: nan

Long-Term/Custodial Nursing Home Care

Coverage details pending

nan

Exclusions: nan

Private-Duty Nursing

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Private hospital rooms and/or private duty nursing are only available during inpatient stays and determined to be medically appropriate by the Plan. Custodial Nursing is not covered by the Plan.

Exclusions: nan

Reconstructive Surgery

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Following a mastectomy, the following services and supplies are covered:1. Surgical services for reconstruction of the breast on which the mastectomy was performed; 2. Surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance; 3. Post-operative breast prostheses; and 4. Mastectomy bras/camisoles and external prosthetics that meet external prosthetic placement needs. During all stages of mastectomy, treatments of physical complications, including lymphedema, are covered. Cosmetic Surgery is covered for reconstructive surgery that constitutes necessary care and treatment of medically diagnosed services required for the prompt repair of accidental injury and any other services required by law. Issuer covers reconstruction of congenital defects and birth abnormalities in accordance with its medical coverage guidelines and/or when required by applicable law. Issuer covers medically necessary complications of breast implants / pectoral implants

Exclusions: Excludes cosmetic surgery and services except for breast reconstruction following medically necessary mastectomy.

Routine Eye Exam (Adult)

Coverage details pending

nan

Exclusions: nan

Routine Foot Care

Coverage details pending

nan

Exclusions: nan

Treatment for Temporomandibular Joint Disorders

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Benefits are payable for covered services and supplies which are necessary to treat TMJ disorder.

Exclusions: nan

Variant attributes

Blue PPO PremierHealth Silver - Statewide PPO Network · Variant 53901AZ1490002-06

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

94% AV Level Silver Plan

HIOS Product ID

53901AZ149

Metal Level

Silver

Plan ID (Standard Component ID with Variant)

53901AZ1490002-06

Plan Marketing Name

Blue PPO PremierHealth Silver - Statewide PPO Network

Plan Variant Marketing Name

Blue PremierHealth Silver 6 Statewide PPO (2 Free In-Network PCP Visits)

Issuer & service area

Issuer-provided metadata for this variant.

Issuer ID

53901

Issuer Marketplace Marketing Name

Blue Cross Blue Shield of Arizona

Market Coverage

Individual

Multiple In Network Tiers

Yes

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.

Service Area ID

AZS013

State Code

AZ

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

0.949198522546667

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

Yes

Medical Drug Maximum Out of Pocket Integrated

Yes

SBC Scenario, Having a Baby, Coinsurance

$390

SBC Scenario, Having a Baby, Copayment

$10

SBC Scenario, Having a Baby, Deductible

$350

SBC Scenario, Having Diabetes, Coinsurance

$330

SBC Scenario, Having Diabetes, Copayment

$70

SBC Scenario, Having Diabetes, Deductible

$350

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$380

SBC Scenario, Treatment of a Simple Fracture, Copayment

$20

SBC Scenario, Treatment of a Simple Fracture, Deductible

$350

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, In Network (Tier 1), Default Coinsurance

20.00%

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

20.00%

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

$1500 per group

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

$750 per person

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

$750

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

$1500 per group

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

$750 per person

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

$750

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

$20000 per group

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

$10000 per person

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

$10,000

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

AZF010

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$50

SBC Scenario, Having Diabetes, Limit

$20

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

2

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Dental Only Plan

No

Design Type

Not Applicable

EHB Percent of Total Premium

1.0

First Tier Utilization

17%

Import Date

2024-09-17 01:02:01

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

Existing

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

No

Plan Effective Date

2025-01-01

Plan Type

PPO

QHP/Non QHP

Both

Second Tier Utilization

83%

Source Name

HIOS

Plan ID

53901AZ1490002

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), Family Per Group

$700 per group

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

$350 per person

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual

$350

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

$700 per group

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

$350 per person

Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual

$350

Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group

$10000 per group

Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person

$5000 per person

Combined Medical and Drug EHB Deductible, Out of Network, Individual

$5,000

Unique Plan Design

No

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 Arizona?

Blue PPO PremierHealth Silver - Statewide PPO Network (53901AZ1490002) is a Silver PPO from Blue Cross Blue Shield of Arizona, Inc. in Arizona 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 Blue PPO PremierHealth Silver - Statewide PPO Network 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 Blue PPO PremierHealth Silver - Statewide PPO Network 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: Child.

Does Blue PPO PremierHealth Silver - Statewide PPO Network support mail-order prescriptions?

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

Is there out-of-country coverage for Blue PPO PremierHealth Silver - Statewide PPO Network?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: Emergencies Only. Authorization required for non-emergent services.

Does Blue PPO PremierHealth Silver - Statewide PPO Network 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: Emergencies, Urgent Care and Authorized Follow-up Care. Urgent Care and Authorized Follow-up Care covered only through contracted providers.

How do I enroll in or manage payments for Blue PPO PremierHealth Silver - Statewide PPO Network?

Use the issuer portal https://ssoprod.healthplan.com/sp/ACS.saml2 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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