my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit - 31274WV0580001 Health Insurance Plan
Highmark Blue Cross Blue Shield West Virginia health insurance plan with the Plan ID 31274WV0580001. The plan is called my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.21% (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 36.79% 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 | 31274WV0580001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | West Virginia | ||||||||||||||||||
| Health Insurance Issuer | Highmark Blue Cross Blue Shield West Virginia | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 31274WV0580001-00 | ||||||||||||||||||
| Provider Network(s) | NONPREFERRED IN-NETWORK PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 13 May 2025 06:05 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 31274WV0580001-00 Standard On Exchange Plan - 31274WV0580001-01 |
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| Last Plan Update Date | Tue, 13 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 13 May 2025 06:05 GMT |
my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan Variant 31274WV0580001-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.632089501764411 |
| 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 | Not Applicable |
| 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 | 0.9987 |
| First Tier Utilization | 100% |
| Formulary ID | WVF007 |
| Formulary URL | URL |
| HIOS Product ID | 31274WV058 |
| Import Date | 2024-08-13 20:01:38 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | Yes |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 31274 |
| Issuer Marketplace Marketing Name | Highmark Blue Cross Blue Shield West Virginia |
| 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 | Yes |
| Network ID | WVN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Coverage is provided through the Blue Cross Blue Shield Global Core when a Member requires Emergency Care Services or Urgent Care Services while traveling or living outside the United States. All Emergency Care Services and Urgent Care Services are covered in accordance within the Member's Agreement. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | If a member receives non-emergency medically necessary and appropriate care from an out-of-area Blue Card provider, benefits will be paid in accordance with the contract. If a member receives non-emergency care from a non-Blue Card provider, services will be covered at the lower, out-of-network level and the member will be financially responsible for the difference between the plan's payment and the full amount of the out-of-area provider's charge. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 31274WV0580001-00 |
| Plan Marketing Name | my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit |
| Plan Type | PPO |
| Plan Variant Marketing Name | my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,400 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,400 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| 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 | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WVS001 |
| Source Name | SERFF |
| Plan ID | 31274WV0580001 |
| State Code | WV |
| 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 | $14800 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7400 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,400 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $29600 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $14800 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $14,800 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $14800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,400 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $29600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $14800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $14,800 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan, 31274WV0580001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit, 31274WV0580001 Health Insurance Plan, 31274WV0580001
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Does my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan, 31274WV0580001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (31274WV0580001) Health Insurance Plan, Variant (31274WV0580001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does (31274WV0580001) Health Insurance Plan, Variant (31274WV0580001-00) have Out Of Country Coverage?
Yes. Details: Coverage is provided through the Blue Cross Blue Shield Global Core when a Member requires Emergency Care Services or Urgent Care Services while traveling or living outside the United States. All Emergency Care Services and Urgent Care Services are covered in accordance within the Member's Agreement.
Does (31274WV0580001) Health Insurance Plan, Variant (31274WV0580001-00) have Out of Service Area Coverage?
Yes. Details: If a member receives non-emergency medically necessary and appropriate care from an out-of-area Blue Card provider, benefits will be paid in accordance with the contract. If a member receives non-emergency care from a non-Blue Card provider, services will be covered at the lower, out-of-network level and the member will be financially responsible for the difference between the plan's payment and the full amount of the out-of-area provider's charge.
Does (31274WV0580001) Health Insurance Plan, Variant (31274WV0580001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan, Variant (31274WV0580001-00) offer Disease Management Programs for Asthma?
Yes, the my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan Variant
31274WV0580001-00 offers Disease
Management Program for Asthma.
Does my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan, Variant (31274WV0580001-00) offer Disease Management Programs for Heart disease?
Yes, the my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan Variant
31274WV0580001-00 offers Disease
Management Program for Heart disease.
Does my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan, Variant (31274WV0580001-00) offer Disease Management Programs for Depression?
Yes, the my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan Variant
31274WV0580001-00 offers Disease
Management Program for Depression.
Does my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan, Variant (31274WV0580001-00) offer Disease Management Programs for Diabetes?
Yes, the my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan Variant
31274WV0580001-00 offers Disease
Management Program for Diabetes.
Does my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan, Variant (31274WV0580001-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan Variant
31274WV0580001-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan, Variant (31274WV0580001-00) offer Disease Management Programs for Low back pain?
Yes, the my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan Variant
31274WV0580001-00 offers Disease
Management Program for Low back pain.
Does my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan, Variant (31274WV0580001-00) offer Disease Management Programs for Pregnancy?
Yes, the my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan Variant
31274WV0580001-00 offers Disease
Management Program for Pregnancy.
Does my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan, Variant (31274WV0580001-00) offer Disease Management Programs for Weight loss programs?
Yes, the my Blue Access WV PPO Bronze 7400 HSA - Custom Drug Benefit Health Insurance Plan Variant
31274WV0580001-00 offers Disease
Management Program for Weight loss programs.
Disclaimer: This is based on the import(Date: Tue, 13 May 2025 06:05 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