Together Blue EPO Gold 1700 HSA - 79279PA0090004 Health Insurance Plan
Highmark Coverage Advantage (HCA) health insurance plan with the Plan ID 79279PA0090004. The plan is called Together Blue EPO Gold 1700 HSA.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.30% (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 20.70% 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 | 79279PA0090004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Pennsylvania | ||||||||||||||||||
| Health Insurance Issuer | Highmark Coverage Advantage (HCA) | ||||||||||||||||||
| Health Insurance Plan Variant | 79279PA0090004-01 | ||||||||||||||||||
| Provider Network(s) | ['PAN002'] | ||||||||||||||||||
| 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 - 79279PA0090004-01 |
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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 |
Together Blue EPO Gold 1700 HSA Health Insurance Plan Variant 79279PA0090004-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.792982166 |
| 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, Depression, Diabetes, Pain Management, Pregnancy, Weight Loss Programs, Low Back Pain, High Blood Pressure & High Cholesterol |
| EHB Percent of Total Premium | 100% |
| First Tier Utilization | 100% |
| Formulary ID | PAF004 |
| HIOS Product ID | 79279PA009 |
| Import Date | 1/23/2023 |
| HSA Eligible | Yes |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 79279 |
| 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 | Yes |
| Network ID | PAN002 |
| 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 | The Plan covers only limited health care services received by a non-Blue Card (out-of-network) provider. Out-of-Network Covered Services include Emergency Care Services and Urgent Care Services. Any other Out-of-Network services will not be covered unless authorized by the Plan. |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 79279PA0090004-01 |
| Plan Marketing Name | Together Blue EPO Gold 1700 HSA |
| Plan Type | EPO |
| Plan Variant Marketing Name | Together Blue EPO Gold 1700 HSA |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $500 |
| SBC Scenario, Having a Baby, Copayment | $600 |
| SBC Scenario, Having a Baby, Deductible | $1,700 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $100 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| SBC Scenario, Having Diabetes, Deductible | $1,700 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $60 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,700 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | PAS001 |
| Source Name | SERFF |
| Plan ID | 79279PA0090004 |
| State Code | PA |
| 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 | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $3400 per person | $3400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,700 |
| 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 | $5700 per person | $11400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,700 |
| 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 | No |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Together Blue EPO Gold 1700 HSA Health Insurance Plan, 79279PA0090004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Together Blue EPO Gold 1700 HSA, 79279PA0090004 Health Insurance Plan, 79279PA0090004
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Does Together Blue EPO Gold 1700 HSA Health Insurance Plan, 79279PA0090004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (79279PA0090004) Health Insurance Plan, Variant (79279PA0090004-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Weight Loss Programs, Low Back Pain, High Blood Pressure & High Cholesterol
Does (79279PA0090004) Health Insurance Plan, Variant (79279PA0090004-01) 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 (79279PA0090004) Health Insurance Plan, Variant (79279PA0090004-01) have Out of Service Area Coverage?
Yes. Details: The Plan covers only limited health care services received by a non-Blue Card (out-of-network) provider. Out-of-Network Covered Services include Emergency Care Services and Urgent Care Services. Any other Out-of-Network services will not be covered unless authorized by the Plan.
Does (79279PA0090004) Health Insurance Plan, Variant (79279PA0090004-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Weight Loss Programs, Low Back Pain, High Blood Pressure & High Cholesterol
Does Together Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (79279PA0090004-01) offer Disease Management Programs for Asthma?
Yes, the Together Blue EPO Gold 1700 HSA Health Insurance Plan Variant
79279PA0090004-01 offers Disease
Management Program for Asthma.
Does Together Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (79279PA0090004-01) offer Disease Management Programs for Heart disease?
Yes, the Together Blue EPO Gold 1700 HSA Health Insurance Plan Variant
79279PA0090004-01 offers Disease
Management Program for Heart disease.
Does Together Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (79279PA0090004-01) offer Disease Management Programs for Depression?
Yes, the Together Blue EPO Gold 1700 HSA Health Insurance Plan Variant
79279PA0090004-01 offers Disease
Management Program for Depression.
Does Together Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (79279PA0090004-01) offer Disease Management Programs for Diabetes?
Yes, the Together Blue EPO Gold 1700 HSA Health Insurance Plan Variant
79279PA0090004-01 offers Disease
Management Program for Diabetes.
Does Together Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (79279PA0090004-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Together Blue EPO Gold 1700 HSA Health Insurance Plan Variant
79279PA0090004-01 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Together Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (79279PA0090004-01) offer Disease Management Programs for Low back pain?
Yes, the Together Blue EPO Gold 1700 HSA Health Insurance Plan Variant
79279PA0090004-01 offers Disease
Management Program for Low back pain.
Does Together Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (79279PA0090004-01) offer Disease Management Programs for Pregnancy?
Yes, the Together Blue EPO Gold 1700 HSA Health Insurance Plan Variant
79279PA0090004-01 offers Disease
Management Program for Pregnancy.
Does Together Blue EPO Gold 1700 HSA Health Insurance Plan, Variant (79279PA0090004-01) offer Disease Management Programs for Weight loss programs?
Yes, the Together Blue EPO Gold 1700 HSA Health Insurance Plan Variant
79279PA0090004-01 offers Disease
Management Program for Weight loss programs.
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