Premera Blue Cross Preferred Gold EPO 1500 - 49831WA1940001 Health Insurance Plan
Premera Blue Cross health insurance plan with the Plan ID 49831WA1940001. The plan is called Premera Blue Cross Preferred Gold EPO 1500.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 79.23% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 20.77% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.26% (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 20.74% 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 | 49831WA1940001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Washington | ||||||||||||||||||
| Health Insurance Issuer | Premera Blue Cross | ||||||||||||||||||
| Health Insurance Plan Variant | 49831WA1940001-01 | ||||||||||||||||||
| Provider Network(s) | ['WAN001'] | ||||||||||||||||||
| 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 | Standard On Exchange Plan - 49831WA1940001-01 |
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| Last Plan Update Date | Mon, 23 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Premera Blue Cross Preferred Gold EPO 1500 Health Insurance Plan Variant 49831WA1940001-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.792583975 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 2 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes |
| EHB Percent of Total Premium | 99.90% |
| First Tier Utilization | 100% |
| Formulary ID | WAF001 |
| HIOS Product ID | 49831WA194 |
| Import Date | 1/23/2023 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 79.23% |
| Issuer ID | 49831 |
| 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 | WAN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Premera Members have access to the Individual Signature network of providers when outside the Service Area. Our Service Area is Franklin, Grays Harbor, King, Kitsap and Pacific counties in Washington. Benefits are not provided for out-of network providers. |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 49831WA1940001-01 |
| Plan Marketing Name | Premera Blue Cross Preferred Gold EPO 1500 |
| Plan Type | EPO |
| Plan Variant Marketing Name | Premera Blue Cross Preferred Gold EPO 1500 |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $3,300 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $800 |
| SBC Scenario, Having Diabetes, Copayment | $300 |
| SBC Scenario, Having Diabetes, Deductible | $1,500 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WAS004 |
| Source Name | SERFF |
| Plan ID | 49831WA1940001 |
| State Code | WA |
| 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 | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $1500 per person | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| TEHBDedOutofNetFamily | per person not applicable | per group 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 | $6800 per person | $13600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,800 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Premera Blue Cross Preferred Gold EPO 1500 Health Insurance Plan, 49831WA1940001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Premera Blue Cross Preferred Gold EPO 1500, 49831WA1940001 Health Insurance Plan, 49831WA1940001
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Does Premera Blue Cross Preferred Gold EPO 1500 Health Insurance Plan, 49831WA1940001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (49831WA1940001) Health Insurance Plan, Variant (49831WA1940001-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes
Does (49831WA1940001) Health Insurance Plan, Variant (49831WA1940001-01) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (49831WA1940001) Health Insurance Plan, Variant (49831WA1940001-01) have Out of Service Area Coverage?
Yes. Details: Premera Members have access to the Individual Signature network of providers when outside the Service Area.
Our Service Area is Franklin, Grays Harbor, King, Kitsap and Pacific counties in Washington.
Benefits are not provided for out-of network providers.
Does (49831WA1940001) Health Insurance Plan, Variant (49831WA1940001-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes
Does Premera Blue Cross Preferred Gold EPO 1500 Health Insurance Plan, Variant (49831WA1940001-01) offer Disease Management Programs for Asthma?
Yes, the Premera Blue Cross Preferred Gold EPO 1500 Health Insurance Plan Variant
49831WA1940001-01 offers Disease
Management Program for Asthma.
Does Premera Blue Cross Preferred Gold EPO 1500 Health Insurance Plan, Variant (49831WA1940001-01) offer Disease Management Programs for Heart disease?
Yes, the Premera Blue Cross Preferred Gold EPO 1500 Health Insurance Plan Variant
49831WA1940001-01 offers Disease
Management Program for Heart disease.
Does Premera Blue Cross Preferred Gold EPO 1500 Health Insurance Plan, Variant (49831WA1940001-01) offer Disease Management Programs for Diabetes?
Yes, the Premera Blue Cross Preferred Gold EPO 1500 Health Insurance Plan Variant
49831WA1940001-01 offers Disease
Management Program for Diabetes.
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