Bronze Essential 8000 With 4 Copay No Deductible Office Visits Individual and Family Network - 77969OR5280010 Health Insurance Plan

Regence BlueCross BlueShield of Oregon health insurance plan with the Plan ID 77969OR5280010. The plan is called Bronze Essential 8000 With 4 Copay No Deductible Office Visits Individual and Family Network.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 77969OR5280010
Health Insurance Plan Year 2023
State Oregon
Health Insurance Issuer Regence BlueCross BlueShield of Oregon
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 77969OR5280010-02
Provider Network(s) ['ORN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Jul 2024 06:37 GMT).

Providers Oregon 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
Available Variants of the Health Plan

Standard Off Exchange Plan - 77969OR5280010-00

Standard On Exchange Plan - 77969OR5280010-01

Open to Indians below 300% FPL - 77969OR5280010-02

Open to Indians above 300% FPL - 77969OR5280010-03

Last Plan Update Date Wed, 17 Aug 2022 00:00 GMT
Last Import Date Tue, 23 Jul 2024 06:37 GMT

Benefits of Bronze Essential 8000 With 4 Copay No Deductible Office Visits Individual and Family Network Health Insurance Plan, 77969OR5280010-02

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
YES

$0.00, 0.00%

100.00%
Accidental Dental
YES

$0.00, 0.00%

100.00%
Acupuncture

Limit: 12.0 Visit(s) per Year

YES

$0.00, 0.00%

100.00%
Allergy Testing
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Chemotherapy
YES

$0.00, 0.00%

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

YES

$0.00, 0.00%

100.00%
Cosmetic Surgery

one attempt to correct a scar or defect that resulted from an accidental injury or treatment for an accidental injury or one attempt to correct a scar or defect on the head or neck that resulted from a surgery (more than one attempt is covered if medically necessary)

YES

$0.00, 0.00%

100.00%
Delivery and All Inpatient Services for Maternity Care
YES

$0.00, 0.00%

100.00%
Dental Check-Up for Children
YES

$0.00, 0.00%

100.00%
Diabetes Education
YES

$0.00, 0.00%

100.00%
Dialysis
YES

$0.00, 0.00%

100.00%
Durable Medical Equipment

Hardware to correct visual defect due to severe medical or surgical problem such as stroke, neurological disease, trauma or eye surgery other than refractive procedures limited to one pair of glasses (frames and lenses) or contact lenses per calendar year.

YES

$0.00, 0.00%

100.00%
Emergency Room Services

Out of service area coverage is available

YES

$0.00, 0.00%

$0.00, 0.00%
Emergency Transportation/Ambulance

Out of service area coverage is available

YES

$0.00, 0.00%

$0.00, 0.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

One pair of lenses and one frame per year (contacts in lieu of glasses)

YES

$0.00, 0.00%

100.00%
Gender Affirming Care

Information about gender affirming care can be found in plan documents.

YES

$0.00, 0.00%

100.00%
Generic Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$0.00, 0.00%

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Year

Visit limit does not apply to treatment of mental health conditions.

YES

$0.00, 0.00%

100.00%
Hearing Aids

Hearing assistance coverage complies with state and federal law

YES

$0.00, 0.00%

100.00%
Home Health Care Services
YES

$0.00, 0.00%

100.00%
Hospice Services

Respite care - max of 5 consecutive days; lifetime max of 30 days

YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Inpatient Physician and Surgical Services
YES

$0.00, 0.00%

100.00%
Laboratory Outpatient and Professional Services
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Mental/Behavioral Health Inpatient Services
YES

$0.00, 0.00%

100.00%
Mental/Behavioral Health Outpatient Services
YES

$0.00, 0.00%

100.00%
Non-Preferred Brand Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$0.00, 0.00%

100.00%
Nutritional Counseling
YES

$0.00, 0.00%

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
YES

$0.00, 0.00%

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

The first 4 in-network PCP, in-network Specialists, and Urgent Care office visits combined per calendar year are not subject to the deductible.

YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Year

Combined limit of 30 visits for OT, ST, and PT. Visit limit does not apply to treatment of mental health conditions.

YES

$0.00, 0.00%

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$0.00, 0.00%

100.00%
Preferred Brand Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$0.00, 0.00%

100.00%
Prenatal and Postnatal Care
YES

$0.00, 0.00%

100.00%
Preventive Care/Screening/Immunization
YES

$0.00, 0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness

The first 4 in-network PCP, in-network Specialists, and Urgent Care office visits combined per calendar year are not subject to the deductible.

YES

$0.00, 0.00%

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

$0.00, 0.00%

100.00%
Radiation
YES

$0.00, 0.00%

100.00%
Reconstructive Surgery
YES

$0.00, 0.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Year

Limit combined with Occupational, Physical, and Speech therapy. Visit limit does not apply to Mental Health/Substance Abuse.

YES

$0.00, 0.00%

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Year

Limit combined with Occupational, Physical, and Speech therapy. Visit limit does not apply to Mental Health/Substance Abuse.

YES

$0.00, 0.00%

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

Limit: 1.0 Exam(s) per Year

YES

$0.00, 0.00%

100.00%
Routine Foot Care

Covered when medically necessary.

YES

$0.00, 0.00%

100.00%
Skilled Nursing Facility

Limit: 60.0 Days per Year

YES

$0.00, 0.00%

100.00%
Specialist Visit

The first 4 in-network PCP, in-network Specialists, and Urgent Care office visits combined per calendar year are not subject to the deductible.

YES

$0.00, 0.00%

100.00%
Specialty Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$0.00, 0.00%

100.00%
Substance Abuse Disorder Inpatient Services
YES

$0.00, 0.00%

100.00%
Substance Abuse Disorder Outpatient Services
YES

$0.00, 0.00%

100.00%
Telehealth-Primary Care Visit
YES

$0.00, 0.00%

100.00%
Telehealth-Specialist Visit
YES

$0.00, 0.00%

100.00%
Tier 1-Zero Cost-Share Preventive Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$0.00, 0.00%

100.00%
Tier 2-Preferred Generic Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$0.00, 0.00%

100.00%
Tier 3-Non-Preferred Generic Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$0.00, 0.00%

100.00%
Tier 4-Preferred Brand Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$0.00, 0.00%

100.00%
Tier 5-Non-Preferred Brand Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$0.00, 0.00%

100.00%
Tier 6-Preferred Specialty Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$0.00, 0.00%

100.00%
Tier 7-Non-Preferred Specialty Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$0.00, 0.00%

100.00%
Transplant
YES

$0.00, 0.00%

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities

Out of service area coverage is available. The first 4 in-network PCP, in-network Specialists, and Urgent Care office visits combined per calendar year are not subject to the deductible.

YES

$0.00, 0.00%

$0.00, 0.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

$0.00, 0.00%

100.00%
X-rays and Diagnostic Imaging
YES

$0.00, 0.00%

100.00%

Bronze Essential 8000 With 4 Copay No Deductible Office Visits Individual and Family Network Health Insurance Plan Variant 77969OR5280010-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Zero Cost Sharing Plan Variation
Dental Only Plan No
Design Type Not Applicable
EHB Percent of Total Premium 0.996
First Tier Utilization 100%
Formulary ID ORF012
Formulary URL URL
HIOS Product ID 77969OR528
Import Date 8/17/2022 20:01
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 77969
Issuer Marketplace Marketing Name Regence BlueCross BlueShield of Oregon
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Expanded Bronze
Multiple In Network Tiers No
National Network No
Network ID ORN001
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 77969OR5280010-02
Plan Marketing Name Bronze Essential 8000 With 4 Copay No Deductible Office Visits Individual and Family Network
Plan Type EPO
Plan Variant Marketing Name Bronze Essential 8000 With 4 Copay No Deductible Office Visits Individual and Family Network
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID ORS001
Source Name SERFF
Plan ID 77969OR5280010
State Code OR
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 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $0
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 $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $0
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 Bronze Essential 8000 With 4 Copay No Deductible Office Visits Individual and Family Network Health Insurance Plan, 77969OR5280010

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

Frequently Asked Questions(FAQ) about Bronze Essential 8000 With 4 Copay No Deductible Office Visits Individual and Family Network, 77969OR5280010 Health Insurance Plan, 77969OR5280010

  • Does Bronze Essential 8000 With 4 Copay No Deductible Office Visits Individual and Family Network Health Insurance Plan, 77969OR5280010 support Mail Ordering?

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

  • Does (77969OR5280010) Health Insurance Plan, Variant (77969OR5280010-02) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (77969OR5280010) Health Insurance Plan, Variant (77969OR5280010-02) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

 

Disclaimer: This is based on the import(Date: Tue, 23 Jul 2024 06:37 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