Alliance Gold 2500 With Vision Exam Legacy LHP - 77969OR5320002 Health Insurance Plan

Regence BlueCross BlueShield of Oregon health insurance plan with the Plan ID 77969OR5320002. The plan is called Alliance Gold 2500 With Vision Exam Legacy LHP.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 77.57% (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 22.43% 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 77969OR5320002
Health Insurance Plan Year 2022
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 77969OR5320002-00
Provider Network(s) ['ORN003']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 21 May 2024 06:25 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 - 77969OR5320002-00

Standard On Exchange Plan - 77969OR5320002-01

Open to Indians below 300% FPL - 77969OR5320002-02

Open to Indians above 300% FPL - 77969OR5320002-03

Last Plan Update Date Fri, 06 Aug 2021 00:00 GMT
Last Import Date Tue, 21 May 2024 06:25 GMT

Alliance Gold 2500 With Vision Exam Legacy LHP Health Insurance Plan Variant 77969OR5320002-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.775678549
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2022
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Gold Off Exchange Plan
Dental Only Plan No
EHB Percent of Total Premium 0.9943
First Tier Utilization 100%
Formulary ID ORF013
Formulary URL URL
HIOS Product ID 77969OR532
Import Date 8/6/2021 20:00
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan New
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 Gold
Multiple In Network Tiers No
National Network No
Network ID ORN003
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan ID (Standard Component ID with Variant) 77969OR5320002-00
Plan Marketing Name Alliance Gold 2500 With Vision Exam Legacy LHP
Plan Type EPO
Plan Variant Marketing Name Alliance Gold 2500 With Vision Exam Legacy LHP
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $972
SBC Scenario, Having a Baby, Copayment $9
SBC Scenario, Having a Baby, Deductible $2,500
SBC Scenario, Having a Baby, Limit $61
SBC Scenario, Having Diabetes, Coinsurance $937
SBC Scenario, Having Diabetes, Copayment $291
SBC Scenario, Having Diabetes, Deductible $877
SBC Scenario, Having Diabetes, Limit $178
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $495
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,090
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID ORS003
Source Name SERFF
Plan ID 77969OR5320002
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 10.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $5000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $2500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $2,500
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 $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
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 Alliance Gold 2500 With Vision Exam Legacy LHP Health Insurance Plan, 77969OR5320002

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

Frequently Asked Questions(FAQ) about Alliance Gold 2500 With Vision Exam Legacy LHP, 77969OR5320002 Health Insurance Plan, 77969OR5320002

  • Does Alliance Gold 2500 With Vision Exam Legacy LHP Health Insurance Plan, 77969OR5320002 support Mail Ordering?

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

  • Does (77969OR5320002) Health Insurance Plan, Variant (77969OR5320002-00) have Out Of Country Coverage?

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

    Does (77969OR5320002) Health Insurance Plan, Variant (77969OR5320002-00) 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, 21 May 2024 06:25 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