Blue StandardHealth Silver - Neighborhood Network - 53901AZ1420145 Health Insurance Plan

Blue Cross and Blue Shield of Arizona, Inc. health insurance plan with the Plan ID 53901AZ1420145. The plan is called Blue StandardHealth Silver - Neighborhood Network.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.01% (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 29.99% 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 53901AZ1420145
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 53901AZ1420145-00
Provider Network(s) NEIGHBORHOOD
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Arizona All US States
All 964 1079
PCP 54 57
Allergy N/A N/A
OB/GYN 1 1
Dentists 401 441
Available Variants of the Health Plan

Standard Off Exchange Plan - 53901AZ1420145-00

Standard On Exchange Plan - 53901AZ1420145-01

Open to Indians below 300% FPL - 53901AZ1420145-02

Open to Indians above 300% FPL - 53901AZ1420145-03

73% AV Silver Plan - 53901AZ1420145-04

87% AV Silver Plan - 53901AZ1420145-05

94% AV Silver Plan - 53901AZ1420145-06

Last Plan Update Date Tue, 17 Sep 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Blue StandardHealth Silver - Neighborhood Network Health Insurance Plan, 53901AZ1420145-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental

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.

YES

40.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

$80.00

100.00%
Bariatric Surgery

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 physician?supervised 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.

YES

$1000.00 Copay with deductible, 40.00% Coinsurance after deductible

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

50.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

40.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

HMOs may limit chiropractic visits to 20.

YES

$80.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

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.

YES

40.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Year

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

YES

No Charge

100.00%
Diabetes Education
YES

No Charge

100.00%
Dialysis
YES

40.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

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.

YES

40.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

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

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs

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

YES

$20.00

100.00%
Habilitation Services

Limit: 60.0 Visit(s) per Year

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

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.

YES

$40.00

100.00%
Hearing Aids

Limit: 1.0 Item(s) per Benefit Period

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

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

YES

40.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 42.0 Visit(s) per Year

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

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.

YES

40.00% Coinsurance after deductible

100.00%
Hospice Services

Exclusions: Excludes respite care.

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.

YES

No Charge

100.00%
Imaging (CT/PET Scans, MRIs)
YES

40.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy

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

YES

40.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

40.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

40.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Inpatient Services

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

YES

40.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

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

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

YES

$40.00

100.00%
Non-Preferred Brand Drugs

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

YES

$80.00 Copay after deductible

100.00%
Nutritional Counseling

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

YES

No Charge

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
YES

50.00% Coinsurance after deductible

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

40.00% Coinsurance after deductible

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

40.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Year

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

Short-term rehabilitative therapy includes services in an outpatient facility or physician?s office that is part of a rehabilitation program., These services may include physical, speech, occupational, cardiac rehabilitation, cognitive and pulmonary rehabilitation therapy. Some services may be subject to copay instead of coinsurance. Visit limit is for all therapy types combined.

YES

40.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

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

YES

$40.00

100.00%
Prenatal and Postnatal Care
YES

$80.00

100.00%
Preventive Care/Screening/Immunization

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.

YES

0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness

24/7 online doctor visits available with BlueCare Anywhere - see SBC for more information.

YES

$40.00

100.00%
Private-Duty Nursing

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.

YES

40.00% Coinsurance after deductible

100.00%
Prosthetic Devices

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

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.

YES

40.00% Coinsurance after deductible

100.00%
Radiation
YES

40.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

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

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

YES

40.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 60.0 Visit(s) per Year

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

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

YES

$40.00

100.00%
Rehabilitative Speech Therapy

Limit: 60.0 Visit(s) per Year

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

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

YES

$40.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

Limit of 1 routine vision exam per calendar year.

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 90.0 Days per Year

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

YES

40.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$80.00

100.00%
Specialty Drugs

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

YES

$350.00 Copay after deductible

100.00%
Substance Abuse Disorder Inpatient Services

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

YES

40.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

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

YES

$40.00

100.00%
Transplant

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.

YES

40.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

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

YES

40.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$60.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care

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

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

40.00% Coinsurance after deductible

100.00%

Blue StandardHealth Silver Neighborhood Health Insurance Plan Variant 53901AZ1420145-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7001186159724491
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 Silver Off Exchange Plan
Dental Only Plan No
Design Type Design 1
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID AZF013
Formulary URL URL
HIOS Product ID 53901AZ142
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 No
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 Silver
Multiple In Network Tiers No
National Network No
Network ID AZN002
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) 53901AZ1420145-00
Plan Level Exclusions Non-covered services and any services related to or associated with non-covered services, non-medically necessary services, and all other benefit specific and general exclusions and limitations listed in the benefit book. This exclusion does not apply to services required by federal or state law to be covered.
Plan Marketing Name Blue StandardHealth Silver - Neighborhood Network
Plan Type HMO
Plan Variant Marketing Name Blue StandardHealth Silver Neighborhood
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,980
SBC Scenario, Having a Baby, Copayment $90
SBC Scenario, Having a Baby, Deductible $5,000
SBC Scenario, Having a Baby, Limit $50
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,250
SBC Scenario, Having Diabetes, Deductible $170
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $330
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,050
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID AZS009
Source Name HIOS
Plan ID 53901AZ1420145
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 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $10000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,000
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
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 Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $16000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Blue StandardHealth Silver - Neighborhood Network Health Insurance Plan, 53901AZ1420145

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Blue StandardHealth Silver - Neighborhood Network, 53901AZ1420145 Health Insurance Plan, 53901AZ1420145

  • Does Blue StandardHealth Silver - Neighborhood Network Health Insurance Plan, 53901AZ1420145 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (53901AZ1420145) Health Insurance Plan, Variant (53901AZ1420145-00) have Out Of Country Coverage?

    Yes. Details: Emergencies Only. Authorization required for non-emergent services.

    Does (53901AZ1420145) Health Insurance Plan, Variant (53901AZ1420145-00) have Out of Service Area Coverage?

    Yes. Details: Emergencies, Urgent Care and Authorized Follow-up Care. Urgent Care and Authorized Follow-up Care covered only through contracted providers.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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