Anthem Bronze Preferred/Broad HSA (+ Incentives) - 79475WI0530004 Health Insurance Plan
Compcare Health Serv Ins Co(Anthem BCBS) health insurance plan with the Plan ID 79475WI0530004. The plan is called Anthem Bronze Preferred/Broad HSA (+ Incentives).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 61.46% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 38.54% 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 61.46% (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 38.54% 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 | 79475WI0530004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Compcare Health Serv Ins Co(Anthem BCBS) | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 79475WI0530004-03 | ||||||||||||||||||
| 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 - 79475WI0530004-00 Standard On Exchange Plan - 79475WI0530004-01 |
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| Last Plan Update Date | Thu, 24 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Anthem Bronze Preferred/Broad HSA (+ Incentives) Health Insurance Plan, 79475WI0530004-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Limited to therapeutic (only in case of rape, incest or health of mother) |
NO | ||
| Accidental Dental
Limit: 3000.0 Dollars per Episode Limited to $900 per tooth |
YES | No Charge after deductible |
No Charge after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
|
NO | ||
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | No Charge after deductible |
No Charge after deductible |
| Chemotherapy
|
YES | No Charge after deductible |
No Charge after deductible |
| Chiropractic Care
Member is responsible for the Primary Care Physician cost share amount when service is performed by a Primary Care Physician or Chiropractor. |
YES | No Charge after deductible |
No Charge after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Excludes services related to surrogacy if member is not the surrogate. |
YES | No Charge after deductible |
No Charge after deductible |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year |
YES | No Charge after deductible |
No Charge after deductible |
| Diabetes Education
|
YES | No Charge after deductible |
No Charge after deductible |
| Dialysis
|
YES | No Charge after deductible |
No Charge after deductible |
| Durable Medical Equipment
Limit: 1.0 Item(s) per 3 Years Limited to a single purchase of a type of Durable Medical Equipment/Prosthetic (including repair and replacement) every 3 years. |
YES | No Charge after deductible |
No Charge after deductible |
| 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 occurrence. |
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
$0.00 |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
30 day supply retail |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 0.00% Coinsurance after deductible |
0.00% Coinsurance after deductible |
| Habilitation Services
Limit: 60.0 Visit(s) per Year 20 visit limit for each Physical Therapy, Occupational Therapy and Speech Therapy |
YES | No Charge after deductible |
No Charge after deductible |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years 1 hearing aid per ear every 3 years |
YES | No Charge after deductible |
No Charge after deductible |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | No Charge after deductible |
No Charge after deductible |
| Hospice Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
No Charge after deductible |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | No Charge after deductible |
No Charge after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis) ? Limited to a maximum of 60 days per Member, per Calendar Year. |
YES | No Charge after deductible |
No Charge after deductible |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Inpatient Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Outpatient Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Non-Preferred Brand Drugs
30 day supply retail |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 0.00% Coinsurance after deductible |
0.00% Coinsurance after deductible |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | No Charge after deductible |
No Charge after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Copay is for Primary Care office visit and Specialist Office visits only, other services provided during the visit are subject to deductible and coinsurance. 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 |
No Charge after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
No Charge after deductible |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year 20 visit limit for each Physical Therapy, Occupational Therapy and Speech Therapy |
YES | No Charge after deductible |
No Charge after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Preferred Brand Drugs
30 day supply retail |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 0.00% Coinsurance after deductible |
0.00% Coinsurance after deductible |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
No Charge after deductible |
| 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. Covered Services also include lead poisoning screening for Dependents under age six (6), as required by state law. |
YES | No Charge |
No Charge after deductible |
| Primary Care Visit to Treat an Injury or Illness
Copay is for Primary Care office visit and Specialist Office visits only, other services provided during the visit are subject to deductible and coinsurance. 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 |
No Charge after deductible |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Limit: 1.0 Item(s) per 3 Years Limit is applicable to a single purchase of a type of prosthetic device. Limit does not apply to prosthetics required by the Women?s Health and Cancer Rights Act of 1998. |
YES | No Charge after deductible |
No Charge after deductible |
| Radiation
|
YES | No Charge after deductible |
No Charge after deductible |
| Reconstructive Surgery
|
YES | No Charge after deductible |
No Charge after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year 20 visits each Physical Therapy/Occupational Therapy per year. Limit is combined across professional visits and outpatient facilities. |
YES | No Charge after deductible |
No Charge after deductible |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Limit is combined across professional visits and outpatient facilities. |
YES | No Charge after deductible |
No Charge after deductible |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
$0.00 |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Admission |
YES | No Charge after deductible |
No Charge after deductible |
| Specialist Visit
Copay is for Primary Care office visit and Specialist Office visits only, other services provided during the visit are subject to deductible and coinsurance. 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 |
No Charge after deductible |
| Specialty Drugs
30 day supply retail |
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 |
No Charge after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Transplant
|
YES | No Charge after deductible |
No Charge after deductible |
| Treatment for Temporomandibular Joint Disorders
Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. Covered Services do not include fixed or removable appliances that involve movement or repositioning of the teeth (braces), repair of teeth (fillings), or prosthetics (crowns, bridges, dentures) |
YES | No Charge after deductible |
No Charge after deductible |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
No Charge after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Benefits are covered under preventive care. |
YES | No Charge |
No Charge after deductible |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
No Charge after deductible |
Anthem Bronze Preferred/Broad (+ Incentives) Health Insurance Plan Variant 79475WI0530004-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.6145897307867839 |
| 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 | Limited Cost Sharing Plan Variation |
| 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 | 1.0 |
| First Tier Utilization | 32% |
| Formulary ID | WIF518 |
| Formulary URL | URL |
| HIOS Product ID | 79475WI053 |
| Import Date | 2024-10-24 01:02:26 |
| 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 Actuarial Value | 61.46% |
| Issuer ID | 79475 |
| 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 | Expanded Bronze |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | WIN003 |
| 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) | 79475WI0530004-03 |
| Plan Marketing Name | Anthem Bronze Preferred/Broad HSA (+ Incentives) |
| Plan Type | POS |
| Plan Variant Marketing Name | Anthem Bronze Preferred/Broad (+ 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 | $8,250 |
| 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 | 68% |
| Service Area ID | WIS010 |
| Source Name | HIOS |
| Plan ID | 79475WI0530004 |
| State Code | WI |
| 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 | $16500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $8250 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $8,250 |
| 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 | $16500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $8250 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $8,250 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $60000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $30000 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $30,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $16500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8250 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,250 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $16500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $8250 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $8,250 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $60000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $30000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $30,000 |
| 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 Preferred/Broad HSA (+ Incentives) Health Insurance Plan, 79475WI0530004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Anthem Bronze Preferred/Broad HSA (+ Incentives), 79475WI0530004 Health Insurance Plan, 79475WI0530004
-
Does Anthem Bronze Preferred/Broad HSA (+ Incentives) Health Insurance Plan, 79475WI0530004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (79475WI0530004) Health Insurance Plan, Variant (79475WI0530004-03) offer Disease Management Programs?
Does (79475WI0530004) Health Insurance Plan, Variant (79475WI0530004-03) have Out Of Country Coverage?
Does (79475WI0530004) Health Insurance Plan, Variant (79475WI0530004-03) have Out of Service Area Coverage?
Does (79475WI0530004) Health Insurance Plan, Variant (79475WI0530004-03) offer Disease Management Programs?
Does Anthem Bronze Preferred/Broad (+ Incentives) Health Insurance Plan, Variant (79475WI0530004-03) offer Disease Management Programs for Asthma?
Does Anthem Bronze Preferred/Broad (+ Incentives) Health Insurance Plan, Variant (79475WI0530004-03) offer Disease Management Programs for Heart disease?
Does Anthem Bronze Preferred/Broad (+ Incentives) Health Insurance Plan, Variant (79475WI0530004-03) offer Disease Management Programs for Depression?
Does Anthem Bronze Preferred/Broad (+ Incentives) Health Insurance Plan, Variant (79475WI0530004-03) offer Disease Management Programs for Diabetes?
Does Anthem Bronze Preferred/Broad (+ Incentives) Health Insurance Plan, Variant (79475WI0530004-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Anthem Bronze Preferred/Broad (+ Incentives) Health Insurance Plan, Variant (79475WI0530004-03) 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