Regence Standard Gold Plan Legacy LHP - 77969OR5290007 Health Insurance Plan

Regence BlueCross BlueShield of Oregon health insurance plan with the Plan ID 77969OR5290007. The plan is called Regence Standard Gold Plan Legacy LHP.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.82% (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 18.18% 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 77969OR5290007
Health Insurance Plan Year 2023
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 77969OR5290007-01
Provider Network(s) ['ORN002']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Jul 2024 06:14 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 - 77969OR5290007-00

Standard On Exchange Plan - 77969OR5290007-01

Open to Indians below 300% FPL - 77969OR5290007-02

Open to Indians above 300% FPL - 77969OR5290007-03

Last Plan Update Date Wed, 17 Aug 2022 00:00 GMT
Last Import Date Tue, 16 Jul 2024 06:14 GMT

Benefits of Regence Standard Gold Plan Legacy LHP Health Insurance Plan, 77969OR5290007-01

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
YES

No Charge

100.00%
Accidental Dental
YES

20.00% Coinsurance after deductible

100.00%
Acupuncture

Limit: 12.0 Visit(s) per Year

YES

$20.00

100.00%
Allergy Testing
YES

20.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

20.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

YES

$20.00

100.00%
Cosmetic Surgery

one attempt to correct a scar or defect that resulted from an accidental injury or treatment for an accidental injury or one attempt to correct a scar or defect on the head or neck that resulted from a surgery (more than one attempt is covered if medically necessary)

YES

20.00% Coinsurance after deductible

100.00%
Delivery and All Inpatient Services for Maternity Care
YES

20.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

No Charge

100.00%
Dialysis
YES

20.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Hardware to correct visual defect due to severe medical or surgical problem such as stroke, neurological disease, trauma or eye surgery other than refractive procedures limited to one pair of glasses (frames and lenses) or contact lenses per calendar year.

YES

20.00% Coinsurance after deductible

100.00%
Emergency Room Services

Out of service area coverage is available

YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Out of service area coverage is available

YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

One pair of lenses and one frame per year (contacts in lieu of glasses)

YES

No Charge

100.00%
Gender Affirming Care

Information about gender affirming care can be found in plan documents.

YES 100.00%
Generic Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$10.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Year

Visit limit does not apply to treatment of mental health conditions.

YES

$20.00

100.00%
Hearing Aids

Hearing assistance coverage complies with state and federal law

YES

20.00% Coinsurance after deductible

100.00%
Home Health Care Services
YES

20.00% Coinsurance after deductible

100.00%
Hospice Services

Respite care - max of 5 consecutive days; lifetime max of 30 days

YES

20.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

20.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

20.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

20.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

20.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

20.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$20.00

100.00%
Non-Preferred Brand Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

50.00%

100.00%
Nutritional Counseling
YES

20.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$20.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

20.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Year

Combined limit of 30 visits for OT, ST, and PT. Visit limit does not apply to treatment of mental health conditions.

YES

$20.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$30.00

100.00%
Prenatal and Postnatal Care
YES

20.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$20.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

20.00% Coinsurance after deductible

100.00%
Radiation
YES

20.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

20.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Year

Limit combined with Occupational, Physical, and Speech therapy. Visit limit does not apply to Mental Health/Substance Abuse.

YES

$20.00

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Year

Limit combined with Occupational, Physical, and Speech therapy. Visit limit does not apply to Mental Health/Substance Abuse.

YES

$20.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

No Charge

100.00%
Routine Foot Care

Covered when medically necessary.

YES

20.00% Coinsurance after deductible

100.00%
Skilled Nursing Facility

Limit: 60.0 Days per Year

YES

20.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$40.00

100.00%
Specialty Drugs

$500 cap per prescription for the Standard Gold Plan. Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

50.00%

100.00%
Substance Abuse Disorder Inpatient Services
YES

20.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$20.00

100.00%
Telehealth-Primary Care Visit
YES

$20.00

100.00%
Telehealth-Specialist Visit
YES

$40.00

100.00%
Tier 1-Zero Cost-Share Preventive Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$0.00

100.00%
Tier 2-Preferred Generic Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$10.00

100.00%
Tier 3-Non-Preferred Generic Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

25.00%

100.00%
Tier 4-Preferred Brand Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

$30.00

100.00%
Tier 5-Non-Preferred Brand Drugs

Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

50.00%

100.00%
Tier 6-Preferred Specialty Drugs

$500 cap per prescription for the Standard Gold Plan. Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

50.00%

100.00%
Tier 7-Non-Preferred Specialty Drugs

$500 cap per prescription for the Standard Gold Plan. Insulin: $80 max out of pocket for 30 day supply prior to deductible

YES

50.00%

100.00%
Transplant
YES

20.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities

Out of service area coverage is available

YES

$60.00

$60.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

20.00% Coinsurance after deductible

100.00%

Regence Standard Gold Plan Legacy LHP Health Insurance Plan Variant 77969OR5290007-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.818197942
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Gold On Exchange Plan
Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 20.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Drug EHB Deductible, In Network (Tier 1), Individual $0
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Out of Network, Individual Not Applicable
Dental Only Plan No
Design Type Design 3
EHB Percent of Total Premium 0.996
First Tier Utilization 100%
Formulary ID ORF011
Formulary URL URL
HIOS Product ID 77969OR529
Import Date 8/17/2022 20:01
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 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 No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 20.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $3600 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $1800 per person
Medical EHB Deductible, In Network (Tier 1), Individual $1,800
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID ORN002
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 77969OR5290007-01
Plan Marketing Name Regence Standard Gold Plan Legacy LHP
Plan Type EPO
Plan Variant Marketing Name Regence Standard Gold Plan Legacy LHP
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,083
SBC Scenario, Having a Baby, Copayment $11
SBC Scenario, Having a Baby, Deductible $1,800
SBC Scenario, Having a Baby, Limit $61
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $684
SBC Scenario, Having Diabetes, Deductible $877
SBC Scenario, Having Diabetes, Limit $178
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $58
SBC Scenario, Treatment of a Simple Fracture, Copayment $205
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID ORS002
Source Name SERFF
Specialty Drug Maximum Coinsurance $500
Plan ID 77969OR5290007
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
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $14600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7300 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,300
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 Regence Standard Gold Plan Legacy LHP Health Insurance Plan, 77969OR5290007

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

Frequently Asked Questions(FAQ) about Regence Standard Gold Plan Legacy LHP, 77969OR5290007 Health Insurance Plan, 77969OR5290007

  • Does Regence Standard Gold Plan Legacy LHP Health Insurance Plan, 77969OR5290007 support Mail Ordering?

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

  • Does (77969OR5290007) Health Insurance Plan, Variant (77969OR5290007-01) have Out Of Country Coverage?

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

    Does (77969OR5290007) Health Insurance Plan, Variant (77969OR5290007-01) 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, 16 Jul 2024 06:14 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