Silver Plan Standardized
75293AR1200026
Silver
PPO
Silver Plan Standardized is a Silver PPO plan by Arkansas Blue Cross and Blue Shield.
IMPORTANT: You are viewing the 2023 version of Silver Plan Standardized 75293AR1200026. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
Silver Plan Standardized is offered in the following counties.
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Plan Overview
This is a plan overview for 2023 version of Silver Plan Standardized 75293AR1200026.
| Insurer: | Arkansas Blue Cross and Blue Shield |
| Network Type: | PPO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 75293AR1200026 |
Cost-Sharing Overview
Silver Plan Standardized offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Silver Plan Standardized includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8,900.00 | $8900 per person | $17800 per group |
| Deductible: | $5,800.00 | $5800 per person | $11600 per group |
| Coinsurance: | 40.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Silver Plan Standardized will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | $17,800.00 | $17800 per person | $35600 per group |
| Out-of-Network Deductible: | $11,600.00 | $11600 per person | $23200 per group |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $5,800.00 |
| Copayment: | $0.00 |
| Coinsurance: | $2,700.00 |
| Limit: | $40.00 |
| Deductible: | $5,800.00 |
| Copayment: | $0.00 |
| Coinsurance: | $600.00 |
| Limit: | $60.00 |
| Deductible: | $1,900.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Silver Plan Standardized?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
Silver Plan Standardized offers the following features and referral requirements.
| Wellness Program: | Yes |
| Disease Program: | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| Notice Pregnancy: | Yes |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | No |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what Silver Plan Standardized covers when you are out of the service area or out of the country.
| Out of Country Coverage: | Yes |
| Out of Country Coverage Description: | Emergency Care |
| Out of Service Area Coverage: | Yes |
| Out of Service Area Coverage Description: | Benefit Reduction |
| National Network: | No |
Additional Benefits and Cost-Sharing
Silver Plan Standardized includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | $40.00 | 50.00% Coinsurance after deductible | |
| Specialist Visit Covered | $80.00 | 50.00% Coinsurance after deductible | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $40.00 | 50.00% Coinsurance after deductible | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Outpatient Surgery Physician/Surgical Services Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Hospice Services Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. If the Covered Person has been diagnosed and certified by the attending Physician as having a terminal illness with a life expectancy of six months or less, the Company will pay the Allowance or Allowable Charge for Hospice Care. The services must be rendered by an entity licensed by the Arkansas Department of Health or other appropriate state licensing agency and accepted by the Company as a Provider. This benefit is subject to the Deductible, Copayment and Coinsurance specified in the Schedule of Benefits. |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Covered | 40.00% Coinsurance after deductible | 100.00% | Requires Prior Approval from the Company. 4 oocyte retrievals or 2 live births from separate pregnancies |
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Not Covered | |||
| Routine Eye Exam (Adult) Covered | No Charge No Charge | 100.00% | 1 Visit(s) per 2 Years |
| Urgent Care Centers or Facilities Covered | $60.00 | 50.00% Coinsurance after deductible | |
| Home Health Care Services Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | 50 Visit(s) per Year Requires Prior Approval from the Company. Coverage is provided for Home Health Services when Coverage Policy supports the need for in-home service and such care is prescribed or ordered by a Physician. Covered Services must be provided through and billed by a licensed home health agency. Covered Services provided in the home include services of a Registered Professional Nurse (R.N.), a Licensed Practical Nurse (L.P.N.) or a Licensed Psychiatric Technical Nurse (L.P.T.N.). |
| Emergency Room Services Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Inpatient Physician and Surgical Services Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | 60 Days per Year Requires Prior Approval from the Company. 1. The admission must be within seven days of release from an inpatient Hospital stay; 2. The Skilled Nursing Facility services are of a temporary nature and increase ability to function. |
| Prenatal and Postnatal Care Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Notification to the Company. Coverage for routine ultrasound is limited to 1. |
| Delivery and All Inpatient Services for Maternity Care Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Childbirth/delivery professional services: 75293AR1200026-01-40% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200026-02-No charge for in-network and out-of-network services; 75293AR1200026-03-40% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200026-04-40% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200026-05-30% Coinsurance after deductible for in-network services and 50% Coinsurance after deductible for out-of-network services; 75293AR1200026-06-25% Coinsurance for in-network services and 50% Coinsurance after deductible for out-of-network services; Coverage for Out of Network newborn services is limited to $2000 per person for all services first 90 days after birth. Coverage requires Prior Notification to the Company. |
| Mental/Behavioral Health Outpatient Services Covered | $40.00 | 50.00% Coinsurance after deductible | |
| Mental/Behavioral Health Inpatient Services Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Substance Abuse Disorder Outpatient Services Covered | $40.00 | 50.00% Coinsurance after deductible | |
| Substance Abuse Disorder Inpatient Services Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Generic Drugs Covered | $20.00 | 100.00% | |
| Preferred Brand Drugs Covered | $40.00 | 100.00% | |
| Non-Preferred Brand Drugs Covered | $80.00 Copay after deductible | 100.00% | |
| Specialty Drugs Covered | $350.00 Copay after deductible | 100.00% | Requires Prior Approval from the Company. |
| Outpatient Rehabilitation Services Covered | $40.00 | 100.00% | 30 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
| Habilitation Services Covered | $40.00 | 100.00% | 30 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro; Limited to a maximum of 180 units for developmental services visits per Covered Person per calendar year. |
| Chiropractic Care Covered | $40.00 | 100.00% | 30 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
| Durable Medical Equipment Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company for services $500 or more |
| Hearing Aids Covered | No Charge No Charge | No Charge No Charge | Coverage is limited to $1400/ear |
| Imaging (CT/PET Scans, MRIs) Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company for high tech radiology services |
| Preventive Care/Screening/Immunization Covered | No Charge No Charge | 100.00% | 1 Visit(s) per Year |
| Routine Foot Care Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | |
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | No Charge No Charge | 100.00% | 1 Exam(s) per Year |
| Eye Glasses for Children Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | 1 Item(s) per Year |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | $40.00 | 100.00% | 30 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $40.00 | 100.00% | 30 Visit(s) per Year Limit is explicitly a combined 30-visit limit for PT, OT, ST and chiro. |
| Well Baby Visits and Care Covered | No Charge No Charge | 100.00% | |
| Laboratory Outpatient and Professional Services Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | |
| X-rays and Diagnostic Imaging Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | |
| Basic Dental Care – Child Not Covered | |||
| Orthodontia – Child Not Covered | |||
| Major Dental Care – Child Not Covered | |||
| Basic Dental Care – Adult Not Covered | |||
| Orthodontia – Adult Not Covered | |||
| Major Dental Care – Adult Not Covered | |||
| Abortion for Which Public Funding is Prohibited Not Covered | |||
| Transplant Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Accidental Dental Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | |
| Dialysis Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Allergy Testing Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | SOB includes ‘allergy services.’ |
| Chemotherapy Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Radiation Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Diabetes Education Covered | No Charge No Charge | 50.00% Coinsurance after deductible | |
| Prosthetic Devices Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company for any device for which cost exceeds $5,000. Replaced no more frequently than once per 3-yr period except when necessary for growth or end of device’s useful life. |
| Infusion Therapy Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Home infusion therapy. |
| Treatment for Temporomandibular Joint Disorders Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Nutritional Counseling Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Coverage is provided for dietary and nutritional counseling services when provided in conjunction with diabetic self-management training, for services needed by covered persons in connection with cleft palate management and for nutritional assessment programs provided in and by a hospital and approved by the company. |
| Reconstructive Surgery Covered | 40.00% Coinsurance after deductible | 100.00% | Requires Prior Approval from the Company. 1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Covered Person; 2. Surgery performed for the removal of a port-wine stain or hemangioma (only on the face) 3. Treatment provided for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria and is Prior Approved by the Company is covered. |
| Gender Affirming Care Covered | 40.00% Coinsurance after deductible | 100.00% | Requires Prior Approval from the Company. |
| Diabetes Care Management Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | |
| Inherited Metabolic Disorder – PKU Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Off Label Prescription Drugs Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Dental Anesthesia Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Gastric Electrical Stimulation Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Well Child Care Covered | No Charge No Charge | 100.00% | |
| Applied Behavior Analysis Based Therapies Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Cochlear Implants Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. One cochlear implant per ear per Covered Person per lifetime |
| Craniofacial Surgery Covered | 40.00% Coinsurance after deductible | 50.00% Coinsurance after deductible | Requires Prior Approval from the Company. |
| Specialty Drugs Tier 2 Covered | $350.00 Copay after deductible | 100.00% | Requires Prior Approval from the Company. |
| Preventive Drugs Covered | No Charge No Charge | 100.00% |
Free Preventive Services
There is no copayment or coinsurance for any of the following Silver Plan Standardized preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Silver Plan Standardized including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
Ready to sign up for Silver Plan Standardized?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904