Anthem Bronze Essential 9200 Adult Dental/Vision (+ Incentives) - 17575IN0700101 Health Insurance Plan
Anthem Ins Companies Inc(Anthem BCBS) health insurance plan with the Plan ID 17575IN0700101. The plan is called Anthem Bronze Essential 9200 Adult Dental/Vision (+ Incentives).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 59.65% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 40.35% 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 59.65% (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 40.35% 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 | 17575IN0700101 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Indiana | ||||||||||||||||||
| Health Insurance Issuer | Anthem Ins Companies Inc(Anthem BCBS) | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 17575IN0700101-01 | ||||||||||||||||||
| Provider Network(s) | PARTICIPATING | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 17575IN0700101-00 Standard On Exchange Plan - 17575IN0700101-01 |
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| Last Plan Update Date | Sat, 02 Nov 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Anthem Bronze Essential 9200 Adult Dental/Vision (+ Incentives) Health Insurance Plan, 17575IN0700101-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Covered only in the case of rape or incest, or for a pregnancy which, as certified by a doctor, places the woman in danger of death unless an abortion is performed (i.e., abortions for which federal funding is allowed). |
NO | ||
| Accidental Dental
Limit: 3000.0 Dollars per Episode Limit is combined in network and out of network. |
YES | No Charge after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
YES | 40.00% |
100.00% |
| Basic Dental Care - Child
|
YES | No Charge after deductible |
100.00% |
| Chemotherapy
|
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
100.00% |
| Dental Anesthesia
Limited to Accidental Dental or a Member less than 19 years of age or a Member with intellectual or physical disability, are covered if the Member requires dental treatment to be given in a Hospital or Outpatient Ambulatory Surgical Facility. |
YES | No Charge after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Diabetes Education
|
YES | No Charge after deductible |
100.00% |
| Dialysis
|
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
Wigs limited to the first one following cancer treatment. |
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
Non-emergency ambulance/transportation out of network is not covered unless authorized. Authorized out of network is limited to $50,000 per trip. |
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Eye glasses are covered once per benefit period for In Network Services. |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Cost share shown is for a 30 day supply. |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 0.00% Coinsurance after deductible |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Year Cost share is driven by provider/setting. Habilitation and rehabilitation visits count toward the rehabilitation limit. PT, OT and ST include an additional 20 visits each for habilitative services. Limits are not combined but separate based on determination of Habilitative Service or Rehabilitative Service) for both in and out of network services.. The limits do not apply to Mental Health and Substance Abuse conditions. |
YES | No Charge after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Hospice Services
|
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). |
YES | No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
YES | 50.00% |
100.00% |
| Major Dental Care - Child
|
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost share determined by services rendered. |
YES | No Charge after deductible |
100.00% |
| Non-Preferred Brand Drugs
Cost share shown is for a 30 day supply. |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 0.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Covered under preventive guidelines and for diabetes. Cost share is driven by provider/setting. |
YES | No Charge after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | No Charge after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Deductible then Covered in Full applies to office visits. Copays do not apply to these services. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application. |
YES | No Charge after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Limited to 20 visits each for Rehabilitative Physical, Occupational and Speech Therapy. Limited to 36 visits for Cardiac Rehabilitation. Cost share determined by service rendered. |
YES | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
Cost share shown is for a 30 day supply. |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 0.00% Coinsurance after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
100.00% |
| Preventive Care/Screening/Immunization
You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Deductible then Covered in Full applies to office visits. Copays do not apply to these services. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application. |
YES | No Charge after deductible |
100.00% |
| Private-Duty Nursing
Limit: 82.0 Visit(s) per Year Private Duty Nursing care provided in home setting is limited to a maximum of 82 visits per Member, per Calendar Year and a maximum of 164 visits per Member, per lifetime. |
YES | No Charge after deductible |
100.00% |
| Prosthetic Devices
|
YES | No Charge after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
Reconstruction is covered when required following a mastectomy and certain other deformities caused by disease, trauma, congenital anomalies and previous therapeutic process. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year Limited to 20 visits each for Rehabilitative Physical, and Occupational Therapy. Cost share determined by service rendered. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Cost share determined by services rendered. |
YES | No Charge after deductible |
100.00% |
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year |
YES | $20.00 |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Benefit Period Eye exams are covered once per benefit period for In Network Services. |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 90.0 Days per Year |
YES | No Charge after deductible |
100.00% |
| Specialist Visit
Deductible then Covered in Full applies to office visits. Copays do not apply to these services. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application. |
YES | No Charge after deductible |
100.00% |
| Specialty Drugs
Cost share shown is for a 30 day supply. |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 0.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Cost share determined by services rendered. |
YES | No Charge after deductible |
100.00% |
| Transplant
$10,000 limit per transplant for transportation and lodging. Unrelated Donor Search is Limited to a maximum of the 10 best matched donors, identified by an authorized registry. |
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Services do not include fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures). |
YES | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
No Charge after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
100.00% |
Anthem Bronze Essential 9200 Adult Dental/Vision (+ Incentives) Health Insurance Plan Variant 17575IN0700101-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.5965205611925151 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management |
| EHB Percent of Total Premium | 0.9728 |
| First Tier Utilization | 71% |
| Formulary ID | INF501 |
| Formulary URL | URL |
| HIOS Product ID | 17575IN070 |
| Import Date | 2024-11-02 01:02:12 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 59.65% |
| Issuer ID | 17575 |
| Issuer Marketplace Marketing Name | Anthem Blue Cross and Blue Shield |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Bronze |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | INN005 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Urgent/Emergency Coverage Only |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | TRAD/PAR network |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 17575IN0700101-01 |
| Plan Marketing Name | Anthem Bronze Essential 9200 Adult Dental/Vision (+ Incentives) |
| Plan Type | HMO |
| Plan Variant Marketing Name | Anthem Bronze Essential 9200 Adult Dental/Vision (+ Incentives) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $9,200 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,400 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 29% |
| Service Area ID | INS021 |
| Source Name | HIOS |
| Plan ID | 17575IN0700101 |
| State Code | IN |
| 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 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person 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 Per Group | $18400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $9200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $9,200 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $18400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $9200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $9,200 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person 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 Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,200 |
| 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 | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Anthem Bronze Essential 9200 Adult Dental/Vision (+ Incentives) Health Insurance Plan, 17575IN0700101
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Anthem Bronze Essential 9200 Adult Dental/Vision (+ Incentives), 17575IN0700101 Health Insurance Plan, 17575IN0700101
-
Does Anthem Bronze Essential 9200 Adult Dental/Vision (+ Incentives) Health Insurance Plan, 17575IN0700101 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (17575IN0700101) Health Insurance Plan, Variant (17575IN0700101-01) offer Disease Management Programs?
Does (17575IN0700101) Health Insurance Plan, Variant (17575IN0700101-01) have Out Of Country Coverage?
Does (17575IN0700101) Health Insurance Plan, Variant (17575IN0700101-01) have Out of Service Area Coverage?
Does (17575IN0700101) Health Insurance Plan, Variant (17575IN0700101-01) offer Disease Management Programs?
Does Anthem Bronze Essential 9200 Adult Dental/Vision (+ Incentives) Health Insurance Plan, Variant (17575IN0700101-01) offer Disease Management Programs for Asthma?
Does Anthem Bronze Essential 9200 Adult Dental/Vision (+ Incentives) Health Insurance Plan, Variant (17575IN0700101-01) offer Disease Management Programs for Heart disease?
Does Anthem Bronze Essential 9200 Adult Dental/Vision (+ Incentives) Health Insurance Plan, Variant (17575IN0700101-01) offer Disease Management Programs for Depression?
Does Anthem Bronze Essential 9200 Adult Dental/Vision (+ Incentives) Health Insurance Plan, Variant (17575IN0700101-01) offer Disease Management Programs for Diabetes?
Does Anthem Bronze Essential 9200 Adult Dental/Vision (+ Incentives) Health Insurance Plan, Variant (17575IN0700101-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Anthem Bronze Essential 9200 Adult Dental/Vision (+ Incentives) Health Insurance Plan, Variant (17575IN0700101-01) offer Disease Management Programs for Low back pain?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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