Preferred Blue PPO Saver with Copayment - 42690MA1380011 Health Insurance Plan
Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc health insurance plan with the Plan ID 42690MA1380011. The plan is called Preferred Blue PPO Saver with Copayment.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.08% (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 28.92% 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 | 42690MA1380011 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Massachusetts | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc | ||||||||||||||||||
| Health Insurance Plan Variant | 42690MA1380011-01 | ||||||||||||||||||
| Provider Network(s) | ['MAN002'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 May 2024 06:08 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Mon, 22 May 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Preferred Blue PPO Saver with Copayment Health Insurance Plan Variant 42690MA1380011-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.710832401 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver On Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, High Blood Pressure & High Cholesterol |
| First Tier Utilization | 100% |
| Formulary ID | MAF005 |
| HIOS Product ID | 42690MA138 |
| HSA/HRA Employer Contribution | No |
| Import Date | 5/22/2023 |
| HSA Eligible | No |
| IsItANewPlan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 42690 |
| Market Coverage | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | MAN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Except emergency, out of network benefits |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Except emergency, out of network benefits |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 42690MA1380011-01 |
| Plan Marketing Name | Preferred Blue PPO Saver with Copayment |
| Plan Type | PPO |
| Plan Variant Marketing Name | Preferred Blue PPO Saver with Copayment |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,000 |
| SBC Scenario, Having a Baby, Deductible | $2,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,300 |
| SBC Scenario, Having Diabetes, Deductible | $2,000 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MAS002 |
| Source Name | SERFF |
| Plan ID | 42690MA1380011 |
| State Code | MA |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family | per person not applicable | per group 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 person not applicable | per group 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 | $2000 per person | $4000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
| TEHBDedOutofNetFamily | $5000 per person | $10000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $5,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $6700 per person | $13400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,700 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $13400 per person | $26800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $13,400 |
| Unique Plan Design | No |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Preferred Blue PPO Saver with Copayment Health Insurance Plan, 42690MA1380011
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Preferred Blue PPO Saver with Copayment, 42690MA1380011 Health Insurance Plan, 42690MA1380011
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Does Preferred Blue PPO Saver with Copayment Health Insurance Plan, 42690MA1380011 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (42690MA1380011) Health Insurance Plan, Variant (42690MA1380011-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, High Blood Pressure & High Cholesterol
Does (42690MA1380011) Health Insurance Plan, Variant (42690MA1380011-01) have Out Of Country Coverage?
Yes. Details: Except emergency, out of network benefits
Does (42690MA1380011) Health Insurance Plan, Variant (42690MA1380011-01) have Out of Service Area Coverage?
Yes. Details: Except emergency, out of network benefits
Does (42690MA1380011) Health Insurance Plan, Variant (42690MA1380011-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, High Blood Pressure & High Cholesterol
Does Preferred Blue PPO Saver with Copayment Health Insurance Plan, Variant (42690MA1380011-01) offer Disease Management Programs for Asthma?
Yes, the Preferred Blue PPO Saver with Copayment Health Insurance Plan Variant
42690MA1380011-01 offers Disease
Management Program for Asthma.
Does Preferred Blue PPO Saver with Copayment Health Insurance Plan, Variant (42690MA1380011-01) offer Disease Management Programs for Heart disease?
Yes, the Preferred Blue PPO Saver with Copayment Health Insurance Plan Variant
42690MA1380011-01 offers Disease
Management Program for Heart disease.
Does Preferred Blue PPO Saver with Copayment Health Insurance Plan, Variant (42690MA1380011-01) offer Disease Management Programs for Depression?
Yes, the Preferred Blue PPO Saver with Copayment Health Insurance Plan Variant
42690MA1380011-01 offers Disease
Management Program for Depression.
Does Preferred Blue PPO Saver with Copayment Health Insurance Plan, Variant (42690MA1380011-01) offer Disease Management Programs for Diabetes?
Yes, the Preferred Blue PPO Saver with Copayment Health Insurance Plan Variant
42690MA1380011-01 offers Disease
Management Program for Diabetes.
Does Preferred Blue PPO Saver with Copayment Health Insurance Plan, Variant (42690MA1380011-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Preferred Blue PPO Saver with Copayment Health Insurance Plan Variant
42690MA1380011-01 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Preferred Blue PPO Saver with Copayment Health Insurance Plan, Variant (42690MA1380011-01) offer Disease Management Programs for Pregnancy?
Yes, the Preferred Blue PPO Saver with Copayment Health Insurance Plan Variant
42690MA1380011-01 offers Disease
Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Tue, 07 May 2024 06:08 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