Bronze Exp Standardized - 75293AR1200029 Health Insurance Plan
USAble Mutual Insurance Company health insurance plan with the Plan ID 75293AR1200029. The plan is called Bronze Exp Standardized.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.81% (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 36.19% 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 | 75293AR1200029 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Arkansas | ||||||||||||||||||
| Health Insurance Issuer | USAble Mutual Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 75293AR1200029-00 | ||||||||||||||||||
| Provider Network(s) | TRUE-BLUE-PPO PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 Oct 2025 05:27 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 75293AR1200029-00 Standard On Exchange Plan - 75293AR1200029-01 |
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| Last Plan Update Date | Thu, 10 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 Oct 2025 05:27 GMT |
Benefits of Bronze Exp Standardized Health Insurance Plan, 75293AR1200029-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan SOB includes 'allergy services.' |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Applied Behavior Analysis Based Therapies
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Exclusions: nan Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
YES | $50.00 |
100.00% |
| Cochlear Implants
Exclusions: nan One cochlear implant per ear per Covered Person per lifetime |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Craniofacial Surgery
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan Childbirth/delivery professional services: 75293AR1200027-01-50% Coinsurance after deductible for in-network and out-of-network services; 75293AR1200027-02-No charge for in-network and out-of-network services; 75293AR1200027-03-50% Coinsurance after deductible for in-network and out-of-network services; Coverage for Out of Network newborn services is limited to $2000 per person for all services first 90 days after birth. Coverage requires Prior Notification to the Company. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Anesthesia
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Care Management
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Diabetes Education
Exclusions: nan nan |
YES | No Charge |
50.00% Coinsurance after deductible |
| Dialysis
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Gastric Electrical Stimulation
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Gender Affirming Care
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Exclusions: nan Mail Order cost: 75293AR1200024-01- $50 Copay in-network, and 75293AR1200024-03- $50 Copay in-network |
YES | $25.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Exclusions: nan Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro; Limited to a maximum of 180 units for developmental services visits per Covered Person per calendar year. |
YES | $50.00 |
100.00% |
| Hearing Aids
Exclusions: nan Coverage is limited to $1400/hearing aid |
YES | 50.00% |
50.00% |
| Home Health Care Services
Limit: 50.0 Visit(s) per Year Exclusions: nan Coverage is provided for Home Health Services when Coverage Policy supports the need for in-home service and such care is prescribed or ordered by a Physician. Covered Services must be provided through and billed by a licensed home health agency. Covered Services provided in the home include services of a Registered Professional Nurse (R.N.), a Licensed Practical Nurse (L.P.N.) or a Licensed Psychiatric Technical Nurse (L.P.T.N.). |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Hospice Services
Exclusions: nan If the Covered Person has been diagnosed and certified by the attending Physician as having a terminal illness with a life expectancy of six months or less, the Company will pay the Allowance or Allowable Charge for Hospice Care. The services must be rendered by an entity licensed by the Arkansas Department of Health or other appropriate state licensing agency and accepted by the Company as a Provider. This benefit is subject to the Deductible, Copayment and Coinsurance specified in the Schedule of Benefits. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
Exclusions: nan 4 oocyte retrievals or 2 live births from separate pregnancies |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
Exclusions: nan Home infusion therapy. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inherited Metabolic Disorder - PKU
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan Requires prior notification to the Company. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: nan Requires prior notification to the Company. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan Cost Sharing does NOT apply to screenings.The cost sharing that displays applies to outpatient evaluation, consultation, and psychotherapy office visits only. All other outpatient services and procedures provided in an office or outpatient facility may be subject to additional cost sharing. Please refer to plan policy documents for detailed information. |
YES | $50.00 |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
Exclusions: nan Mail Order cost: 75293AR1200024-01- $200 Copay after deductible in-network, and 75293AR1200024-03- $200 Copay after deductible in-network |
YES | $100.00 Copay after deductible |
100.00% |
| Nutritional Counseling
Exclusions: nan Coverage is provided for dietary and nutritional counseling services when provided in conjunction with diabetic self-management training, for services needed by covered persons in connection with cleft palate management and for nutritional assessment programs provided in and by a hospital and approved by the Company. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Off Label Prescription Drugs
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $50.00 |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Exclusions: nan Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
YES | $50.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
Exclusions: nan Mail Order cost: 75293AR1200024-01- $100 Copay after deductible in-network, and 75293AR1200024-03- $100 Copay after deductible in-network |
YES | $50.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan Requires Prior Notification to the Company. Coverage for routine ultrasound is limited to 1. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
Limit: 1.0 Visit(s) per Year Exclusions: nan nan |
YES | 0.00% |
100.00% |
| Preventive Drugs
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan nan |
YES | $50.00 |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
Exclusions: nan nan |
NO | ||
| Prosthetic Devices
Exclusions: nan Replaced no more frequently than once per 3-yr period except when necessary for growth or end of device's useful life. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
Exclusions: nan 1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Covered Person; 2. Surgery performed for the removal of a port-wine stain or hemangioma (only on the face) 3. Treatment provided for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Exclusions: nan Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
YES | $50.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Exclusions: nan Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
YES | $50.00 |
100.00% |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per 2 Years Exclusions: nan nan |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Exclusions: nan nan |
YES | No Charge |
100.00% |
| Routine Foot Care
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Skilled Nursing Facility
Limit: 60.0 Days per Year Exclusions: nan 1. The admission must be within seven days of release from an inpatient Hospital stay; 2. The Skilled Nursing Facility services are of a temporary nature and increase ability to function. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
Exclusions: nan nan |
YES | $100.00 |
50.00% Coinsurance after deductible |
| Specialty Drugs
Exclusions: nan Requires Prior Approval from the Company. |
YES | $500.00 Copay after deductible |
100.00% |
| Specialty Drugs Tier 2
Exclusions: nan Requires Prior Approval from the Company. |
YES | $500.00 Copay after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan Requires prior notification to the Company. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan nan |
YES | $50.00 |
50.00% Coinsurance after deductible |
| Transplant
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $75.00 |
50.00% Coinsurance after deductible |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Well Child Care
Exclusions: nan nan |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Bronze Exp Standardized Health Insurance Plan Variant 75293AR1200029-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.638091065338329 |
| 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 Bronze Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.9994 |
| First Tier Utilization | 100% |
| Formulary ID | ARF006 |
| Formulary URL | URL |
| HIOS Product ID | 75293AR120 |
| Import Date | 2024-10-10 20:01:47 |
| 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 | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 75293 |
| Issuer Marketplace Marketing Name | Arkansas Blue Cross and Blue Shield |
| 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 | ARN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Care |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Benefit Reduction |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 75293AR1200029-00 |
| Plan Level Exclusions | No |
| Plan Marketing Name | Bronze Exp Standardized |
| Plan Type | PPO |
| Plan Variant Marketing Name | Bronze Exp Standardized |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,600 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,500 |
| SBC Scenario, Having a Baby, Limit | $40 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $7,300 |
| SBC Scenario, Having Diabetes, Limit | $60 |
| 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 | $1,900 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ARS001 |
| Source Name | SERFF |
| Plan ID | 75293AR1200029 |
| State Code | AR |
| 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 | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $15000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $27000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $13500 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $13,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $30400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $15200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $15,200 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Bronze Exp Standardized Health Insurance Plan, 75293AR1200029
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Bronze Exp Standardized, 75293AR1200029 Health Insurance Plan, 75293AR1200029
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Does Bronze Exp Standardized Health Insurance Plan, 75293AR1200029 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (75293AR1200029) Health Insurance Plan, Variant (75293AR1200029-00) offer Disease Management Programs?
Does (75293AR1200029) Health Insurance Plan, Variant (75293AR1200029-00) have Out Of Country Coverage?
Does (75293AR1200029) Health Insurance Plan, Variant (75293AR1200029-00) have Out of Service Area Coverage?
Does (75293AR1200029) Health Insurance Plan, Variant (75293AR1200029-00) offer Disease Management Programs?
Does Bronze Exp Standardized Health Insurance Plan, Variant (75293AR1200029-00) offer Disease Management Programs for Asthma?
Does Bronze Exp Standardized Health Insurance Plan, Variant (75293AR1200029-00) offer Disease Management Programs for Heart disease?
Does Bronze Exp Standardized Health Insurance Plan, Variant (75293AR1200029-00) offer Disease Management Programs for Depression?
Does Bronze Exp Standardized Health Insurance Plan, Variant (75293AR1200029-00) offer Disease Management Programs for Diabetes?
Does Bronze Exp Standardized Health Insurance Plan, Variant (75293AR1200029-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Bronze Exp Standardized Health Insurance Plan, Variant (75293AR1200029-00) offer Disease Management Programs for Low back pain?
Does Bronze Exp Standardized Health Insurance Plan, Variant (75293AR1200029-00) offer Disease Management Programs for Pregnancy?
Does Bronze Exp Standardized Health Insurance Plan, Variant (75293AR1200029-00) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 07 Oct 2025 05:27 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