Clear Silver - 91450AZ0080097 Health Insurance Plan
Health Net of Arizona, Inc. health insurance plan with the Plan ID 91450AZ0080097. The plan is called Clear Silver.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 87.75% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 12.25% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 91450AZ0080097 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Arizona | ||||||||||||||||||
| Health Insurance Issuer | Health Net of Arizona, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 91450AZ0080097-05 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 11 Nov 2025 05:33 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 91450AZ0080097-00 Standard On Exchange Plan - 91450AZ0080097-01 Open to Indians below 300% FPL - 91450AZ0080097-02 Open to Indians above 300% FPL - 91450AZ0080097-03 73% AV Silver Plan - 91450AZ0080097-04 |
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| Last Plan Update Date | Thu, 15 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 11 Nov 2025 05:33 GMT |
Benefits of Clear Silver Health Insurance Plan, 91450AZ0080097-05
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan nan |
YES | $45.00 |
100.00% |
| Bariatric Surgery
Exclusions: nan 1. The patient must have a body-mass index (BMI) greather 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 Center of Excellence facility that is credentialed by your Health Network to perform bariatric surgery.; 5. The member must be 18 years or older, or have reached full expected skeletal growth. |
YES | No Charge after deductible |
100.00% |
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year Exclusions: nan HMOs may limit chiropractic visits to 20; PPOs must cover medically necessary chiropractic visits. |
YES | $45.00 |
100.00% |
| Clinical Trials
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Care Management
Exclusions: nan nan |
YES | $45.00 |
100.00% |
| Diabetes Education
Exclusions: nan nan |
YES | $45.00 |
100.00% |
| Dialysis
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
Exclusions: nan nan |
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
Exclusions: nan Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: nan nan |
YES | No Charge |
100.00% |
| Gender Affirming Care
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Generic Drugs
Exclusions: nan Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information. |
YES | No Charge after deductible |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Year Exclusions: nan Limited to 60 visits per year (combined for outpatient physical, speech, occupational, cardiac and pulmonary therapy). |
YES | No Charge after deductible |
100.00% |
| Hearing Aids
Limit: 2.0 Item(s) per Year Exclusions: nan Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit. |
YES | No Charge after deductible |
100.00% |
| Home Health Care Services
Limit: 42.0 Visit(s) per Year Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Hospice Services
Exclusions: Respite Care is not a covered benefit. nan |
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
Exclusions: nan Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). |
NO | ||
| Infusion Therapy
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Inherited Metabolic Disorder - PKU
Exclusions: nan nan |
YES | $15.00 |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | $15.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan Long Term Acute Care is a covered benefit. Long Term Nursing Care/Custodial Care is not a covered benefit. |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
NO | ||
| Mental/Behavioral Health Emergency Room
Exclusions: nan nan |
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Emergency Transportation/Ambulance
Exclusions: nan Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health ER Physician Fee
Exclusions: nan nan |
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Inpatient Services
Exclusions: nan Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. Cost share will be waived for Behavioral Health screening services. |
YES | $25.00 |
100.00% |
| Mental/Behavioral Health Urgent Care
Exclusions: nan nan |
YES | $25.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
Exclusions: nan nan |
YES | $45.00 |
100.00% |
| Off Label Prescription Drugs
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $25.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Exclusions: nan Limited to 60 visits per year (combined for outpatient physical, speech, occupational, cardiac and pulmonary therapy). Note: This visit limit does not apply when treatment is provided for a mental health/substance use disorder diagnosis. |
YES | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan nan |
YES | $25.00 |
100.00% |
| Prescription Drugs Other
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan Covered in accordance with ACA guidelines. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan Unlimited Virtual 24/7 Care Visits received from Ambetters designated telehealth provider covered at No Charge, except for HSAs. |
YES | $25.00 |
100.00% |
| Private-Duty Nursing
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Prosthetic Devices
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Radiation
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Year Exclusions: nan Limited to 60 visits per year (combined for outpatient physical, speech, occupational, cardiac and pulmonary therapy). Note: This visit limit does not apply when treatment is provided for a mental health/substance use disorder diagnosis. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 60.0 Visit(s) per Year Exclusions: nan Limited to 60 visits per year (combined for outpatient physical, speech, occupational, cardiac and pulmonary therapy). Note: This visit limit does not apply when treatment is provided for a mental health/substance use disorder diagnosis. |
YES | No Charge after deductible |
100.00% |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Exclusions: nan nan |
NO | ||
| 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 | $45.00 |
100.00% |
| Skilled Nursing Facility
Limit: 90.0 Days per Year Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $45.00 |
100.00% |
| Specialty Drugs
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan Prior authorization may be required - please contact the number listed on your ID card. |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. Cost share will be waived for Behavioral Health screening services. |
YES | $25.00 |
100.00% |
| Substance Use Disorder Emergency Room
Exclusions: nan nan |
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder Emergency Transportation/Ambulance
Exclusions: nan Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder ER Physician Fee
Exclusions: nan nan |
YES | No Charge after deductible |
No Charge after deductible |
| Substance Use Disorder Outpatient Other Services
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Substance Use Disorder Urgent Care
Exclusions: nan nan |
YES | $25.00 |
100.00% |
| Tier 1b Generic Drugs
Exclusions: nan Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Refer to the prescription drug list for more information. |
YES | No Charge after deductible |
100.00% |
| Transplant
Exclusions: nan Limited to $10,000 for transportation & lodging per transplant. |
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $25.00 |
100.00% |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan Covered in accordance with ACA guidelines. |
YES | No Charge |
100.00% |
| Wigs
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
Clear Silver Health Insurance Plan Variant 91450AZ0080097-05 Attributes
| Plan Attribute | Value |
|---|---|
| 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 | 87% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Diabetes, Heart Disease, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | AZF004 |
| Formulary URL | URL |
| HIOS Product ID | 91450AZ008 |
| Import Date | 2024-08-15 01:01:23 |
| 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 Actuarial Value | 87.75% |
| Issuer ID | 91450 |
| Issuer Marketplace Marketing Name | Ambetter from Arizona Complete Health |
| 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 | AZN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 91450AZ0080097-05 |
| Plan Marketing Name | Clear Silver |
| Plan Type | HMO |
| Plan Variant Marketing Name | Clear Silver |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $300 |
| SBC Scenario, Having a Baby, Deductible | $1,700 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $300 |
| SBC Scenario, Having Diabetes, Deductible | $1,700 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $10 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,900 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | AZS001 |
| Source Name | HIOS |
| Plan ID | 91450AZ0080097 |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3900 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1950 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,950 |
| 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 | $3900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $1950 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $1,950 |
| 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 | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Clear Silver Health Insurance Plan, 91450AZ0080097
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Clear Silver, 91450AZ0080097 Health Insurance Plan, 91450AZ0080097
-
Does Clear Silver Health Insurance Plan, 91450AZ0080097 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (91450AZ0080097) Health Insurance Plan, Variant (91450AZ0080097-05) offer Disease Management Programs?
Does (91450AZ0080097) Health Insurance Plan, Variant (91450AZ0080097-05) have Out Of Country Coverage?
Does (91450AZ0080097) Health Insurance Plan, Variant (91450AZ0080097-05) have Out of Service Area Coverage?
Does (91450AZ0080097) Health Insurance Plan, Variant (91450AZ0080097-05) offer Disease Management Programs?
Does Clear Silver Health Insurance Plan, Variant (91450AZ0080097-05) offer Disease Management Programs for Asthma?
Does Clear Silver Health Insurance Plan, Variant (91450AZ0080097-05) offer Disease Management Programs for Heart disease?
Does Clear Silver Health Insurance Plan, Variant (91450AZ0080097-05) offer Disease Management Programs for Diabetes?
Does Clear Silver Health Insurance Plan, Variant (91450AZ0080097-05) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 11 Nov 2025 05:33 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