Anthem Gold Pathway X Enhanced 1500/25% ($0 Virtual PCP + $0 Select Drugs) Standard - 96751NH0150210 Health Insurance Plan
Matthew Thornton Hlth Plan(Anthem BCBS) health insurance plan with the Plan ID 96751NH0150210. The plan is called Anthem Gold Pathway X Enhanced 1500/25% ($0 Virtual PCP + $0 Select Drugs) Standard.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.06% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.94% 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 78.06% (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 21.94% 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 | 96751NH0150210 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | New Hampshire | ||||||||||||||||||
| Health Insurance Issuer | Matthew Thornton Hlth Plan(Anthem BCBS) | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 96751NH0150210-03 | ||||||||||||||||||
| 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 - 96751NH0150210-00 Standard On Exchange Plan - 96751NH0150210-01 |
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| Last Plan Update Date | Wed, 16 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Anthem Gold Pathway X Enhanced 1500/25% ($0 Virtual PCP + $0 Select Drugs) Standard Health Insurance Plan, 96751NH0150210-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
no coverage except limited to therapeutic coverage (only in case of rape, incest or health of mother) |
NO | ||
| Accidental Dental
Benefits are available for dental work that is Medically Necessary due to an accidental injury to sound natural teeth and gums when the course of treatment for the accidental injury is received or authorized within 3 months of the date of the injury. |
YES | $60.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
Benefits are available for bariatric surgery that is Medically Necessary for the treatment of diseases and ailments caused by or resulting from obesity or morbid obesity. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Year |
YES | $30.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $60.00 |
100.00% |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Coverage for external breast prostheses is limited to 2 prostheses per breast, per Calendar Year. Coverage for post-mastectomy bras is limited to 3 bras per Member, per Calendar Year |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Emergency Room Facility Fee Cost Share is waived if member is admitted to the hospital. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance 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 | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Cost share is for a 30 day supply.? 90 day supply is available with additional cost shares. |
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year Limit is combined across professional visits and outpatient facilities. Benefit limit does not apply when related to Autism. |
YES | $30.00 |
100.00% |
| Hearing Aids
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Hospice Beareavement is not covered. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Exclusions: The benefits do not include artificial insemination (AI) services or assisted reproductive technologies (ART) services or the diagnostic tests and Drugs to support AI or ART services. Examples of ART include in-vitro fertilization, zygote intrafallopian transfer (ZIFT), or gamete intrafallopian transfer (GIFT). Covered Services include diagnostic tests to find the cause of infertility, such as diagnostic laparoscopy, endometrial biopsy, and semen analysis. Benefits also include services to treat the underlying medical conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
The cost sharing that displays applies to outpatient office visits. Similar services provided in an Outpatient Hospital setting may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
Cost share is for a 30 day supply.? 90 day supply is available with additional cost shares. |
YES | $60.00 |
100.00% |
| Nutritional Counseling
|
YES | $30.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
You have $0 virtual visits and medical chats using our preferred virtual care-only Primary Care Physicians (PCP). These services can be accessed via our Sydney application or member website. |
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year Limit is combined across professional visits and outpatient facilities. Benefit limit does not apply when related to Autism. |
YES | $30.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Cost share is for a 30 day supply.? 90 day supply is available with additional cost shares. |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
You have $0 virtual visits and medical chats using our preferred virtual care-only Primary Care Physicians (PCP). These services can be accessed via our Sydney application or member website. |
YES | $30.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Exclusions: Occupational therapy does not include recreational or vocational therapies, such as hobbies, arts and crafts. Limit is combined across professional visits and outpatient facilities. Benefit limit does not apply when related to Autism. |
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Limit is combined across professional visits and outpatient facilities. Benefit limit does not apply when related to Autism. |
YES | $30.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year This Plan covers a complete eye exam and if needed, dilation. |
YES | No Charge |
100.00% |
| Routine Foot Care
Covered if medically necessary for illness or injury. |
YES | $60.00 |
100.00% |
| Skilled Nursing Facility
Limit: 100.0 Days per Year Exclusions: Custodial Care is not a Covered Service. When you require Inpatient skilled nursing and related services for convalescent and rehabilitative care, Covered Services are available if the Facility is licensed or certified under state law as a Skilled Nursing Facility. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
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 | $60.00 |
100.00% |
| Specialty Drugs
Cost share is for a 30 day supply. |
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
The cost sharing that displays applies to outpatient office visits. Similar services provided in an Outpatient Hospital setting may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $30.00 |
100.00% |
| Transplant
Limited to a maximum of the 10 best matched donors, identified by an authorized registry. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $45.00 |
$45.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Benefits are covered under preventive care. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Anthem Gold Pathway X Enhanced 1500/25% ($0 Virtual PCP + $0 Select Drugs) Standard LCSR Health Insurance Plan Variant 96751NH0150210-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7806125763529309 |
| 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 | Design 1 |
| 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 | 100% |
| Formulary ID | NHF510 |
| Formulary URL | URL |
| HIOS Product ID | 96751NH015 |
| Import Date | 2024-10-16 20:01:50 |
| 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 | 78.06% |
| Issuer ID | 96751 |
| 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 | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | NHN006 |
| 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) | 96751NH0150210-03 |
| Plan Marketing Name | Anthem Gold Pathway X Enhanced 1500/25% ($0 Virtual PCP + $0 Select Drugs) Standard |
| Plan Type | HMO |
| Plan Variant Marketing Name | Anthem Gold Pathway X Enhanced 1500/25% ($0 Virtual PCP + $0 Select Drugs) Standard LCSR |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,800 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,400 |
| SBC Scenario, Having Diabetes, Deductible | $100 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NHS001 |
| Source Name | SERFF |
| Plan ID | 96751NH0150210 |
| State Code | NH |
| 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| 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 | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| 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 Gold Pathway X Enhanced 1500/25% ($0 Virtual PCP + $0 Select Drugs) Standard Health Insurance Plan, 96751NH0150210
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Anthem Gold Pathway X Enhanced 1500/25% ($0 Virtual PCP + $0 Select Drugs) Standard, 96751NH0150210 Health Insurance Plan, 96751NH0150210
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Does Anthem Gold Pathway X Enhanced 1500/25% ($0 Virtual PCP + $0 Select Drugs) Standard Health Insurance Plan, 96751NH0150210 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (96751NH0150210) Health Insurance Plan, Variant (96751NH0150210-03) offer Disease Management Programs?
Does (96751NH0150210) Health Insurance Plan, Variant (96751NH0150210-03) have Out Of Country Coverage?
Does (96751NH0150210) Health Insurance Plan, Variant (96751NH0150210-03) have Out of Service Area Coverage?
Does (96751NH0150210) Health Insurance Plan, Variant (96751NH0150210-03) offer Disease Management Programs?
Does Anthem Gold Pathway X Enhanced 1500/25% ($0 Virtual PCP + $0 Select Drugs) Standard LCSR Health Insurance Plan, Variant (96751NH0150210-03) offer Disease Management Programs for Asthma?
Does Anthem Gold Pathway X Enhanced 1500/25% ($0 Virtual PCP + $0 Select Drugs) Standard LCSR Health Insurance Plan, Variant (96751NH0150210-03) offer Disease Management Programs for Heart disease?
Does Anthem Gold Pathway X Enhanced 1500/25% ($0 Virtual PCP + $0 Select Drugs) Standard LCSR Health Insurance Plan, Variant (96751NH0150210-03) offer Disease Management Programs for Depression?
Does Anthem Gold Pathway X Enhanced 1500/25% ($0 Virtual PCP + $0 Select Drugs) Standard LCSR Health Insurance Plan, Variant (96751NH0150210-03) offer Disease Management Programs for Diabetes?
Does Anthem Gold Pathway X Enhanced 1500/25% ($0 Virtual PCP + $0 Select Drugs) Standard LCSR Health Insurance Plan, Variant (96751NH0150210-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Anthem Gold Pathway X Enhanced 1500/25% ($0 Virtual PCP + $0 Select Drugs) Standard LCSR Health Insurance Plan, Variant (96751NH0150210-03) 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