VantageBlue 100/80 750/1500 - 15287RI0490014 Health Insurance Plan
Blue Cross & Blue Shield of Rhode Island health insurance plan with the Plan ID 15287RI0490014. The plan is called VantageBlue 100/80 750/1500.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 90.56% (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 9.44% 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 | 15287RI0490014 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Rhode Island | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross & Blue Shield of Rhode Island | ||||||||||||||||||
| Health Insurance Plan Variant | 15287RI0490014-01 | ||||||||||||||||||
| Provider Network(s) | ['RIN001'] | ||||||||||||||||||
| 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, 23 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
VantageBlue 100/80 750/1500 Health Insurance Plan Variant 15287RI0490014-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.905620529 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Platinum On Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy, Weight Loss Programs, Low Back Pain, High Blood Pressure & High Cholesterol |
| First Tier Utilization | 100% |
| Formulary ID | RIF001 |
| HIOS Product ID | 15287RI049 |
| HSA/HRA Employer Contribution | No |
| Import Date | 1/23/2023 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 15287 |
| Market Coverage | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Platinum |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | RIN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Coverage for urgent or emergent care only as well as medically necessary services. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Coverage for urgent or emergent care only as well as medically necessary services. |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 15287RI0490014-01 |
| Plan Level Exclusions | This plan does not include coverage that is not medically necessary. Abortions for which federal funding is not allowed in accordance with the Affordable Care Act section 130(b)(1)(B)(i) are not covered, namely all abortions except in the case of rape or incest, or for a pregnancy which places the woman in danger of death unless the abortion is performed. This plan does not cover services rendered by excluded providers, naturopaths, homeopaths, providers or facilities who are not legally qualified or licensed, Christian Scientist Practitioners, Acupuncturists, or Massage Therapists. |
| Plan Marketing Name | VantageBlue 100/80 750/1500 |
| Plan Type | PPO |
| Plan Variant Marketing Name | VantageBlue 100/80 750/1500 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $40 |
| SBC Scenario, Having a Baby, Deductible | $750 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| SBC Scenario, Having Diabetes, Deductible | $500 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $50 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | RIS001 |
| Source Name | SERFF |
| Plan ID | 15287RI0490014 |
| State Code | RI |
| 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 | $750 per person | $1500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $750 |
| TEHBDedOutofNetFamily | $3000 per person | $6000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $3,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $1700 per person | $3400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $1,700 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $6800 per person | $13600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $6,800 |
| Unique Plan Design | No |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of VantageBlue 100/80 750/1500 Health Insurance Plan, 15287RI0490014
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about VantageBlue 100/80 750/1500, 15287RI0490014 Health Insurance Plan, 15287RI0490014
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Does VantageBlue 100/80 750/1500 Health Insurance Plan, 15287RI0490014 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (15287RI0490014) Health Insurance Plan, Variant (15287RI0490014-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy, Weight Loss Programs, Low Back Pain, High Blood Pressure & High Cholesterol
Does (15287RI0490014) Health Insurance Plan, Variant (15287RI0490014-01) have Out Of Country Coverage?
Yes. Details: Coverage for urgent or emergent care only as well as medically necessary services.
Does (15287RI0490014) Health Insurance Plan, Variant (15287RI0490014-01) have Out of Service Area Coverage?
Yes. Details: Coverage for urgent or emergent care only as well as medically necessary services.
Does (15287RI0490014) Health Insurance Plan, Variant (15287RI0490014-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy, Weight Loss Programs, Low Back Pain, High Blood Pressure & High Cholesterol
Does VantageBlue 100/80 750/1500 Health Insurance Plan, Variant (15287RI0490014-01) offer Disease Management Programs for Asthma?
Yes, the VantageBlue 100/80 750/1500 Health Insurance Plan Variant
15287RI0490014-01 offers Disease
Management Program for Asthma.
Does VantageBlue 100/80 750/1500 Health Insurance Plan, Variant (15287RI0490014-01) offer Disease Management Programs for Heart disease?
Yes, the VantageBlue 100/80 750/1500 Health Insurance Plan Variant
15287RI0490014-01 offers Disease
Management Program for Heart disease.
Does VantageBlue 100/80 750/1500 Health Insurance Plan, Variant (15287RI0490014-01) offer Disease Management Programs for Diabetes?
Yes, the VantageBlue 100/80 750/1500 Health Insurance Plan Variant
15287RI0490014-01 offers Disease
Management Program for Diabetes.
Does VantageBlue 100/80 750/1500 Health Insurance Plan, Variant (15287RI0490014-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the VantageBlue 100/80 750/1500 Health Insurance Plan Variant
15287RI0490014-01 offers Disease
Management Program for High blood pressure & high cholesterol.
Does VantageBlue 100/80 750/1500 Health Insurance Plan, Variant (15287RI0490014-01) offer Disease Management Programs for Low back pain?
Yes, the VantageBlue 100/80 750/1500 Health Insurance Plan Variant
15287RI0490014-01 offers Disease
Management Program for Low back pain.
Does VantageBlue 100/80 750/1500 Health Insurance Plan, Variant (15287RI0490014-01) offer Disease Management Programs for Pregnancy?
Yes, the VantageBlue 100/80 750/1500 Health Insurance Plan Variant
15287RI0490014-01 offers Disease
Management Program for Pregnancy.
Does VantageBlue 100/80 750/1500 Health Insurance Plan, Variant (15287RI0490014-01) offer Disease Management Programs for Weight loss programs?
Yes, the VantageBlue 100/80 750/1500 Health Insurance Plan Variant
15287RI0490014-01 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