Anthem Gold Pathway X HMO 1500/25% Standard - 49046GA0410175 Health Insurance Plan
Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. health insurance plan with the Plan ID 49046GA0410175. The plan is called Anthem Gold Pathway X HMO 1500/25% Standard.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.02% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.98% 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 78.02% (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 21.98% 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 | 49046GA0410175 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Georgia | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 49046GA0410175-00 | ||||||||||||||||||
| 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). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 49046GA0410175-00 Standard On Exchange Plan - 49046GA0410175-01 |
||||||||||||||||||
| Last Plan Update Date | Thu, 17 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Anthem Gold Pathway X HMO 1500/25% Standard Health Insurance Plan, 49046GA0410175-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Cost share is driven by provider/setting. |
YES | $60.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Cost share is driven by provider/setting. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Bone Marrow Testing
Limit: 10000.0 Dollars per Procedure In-Network Transplant Transportation and Lodging $10,000 Maximum benefit limit per Transplant Unrelated Donor Search $30,000 Maximum benefit limit per Transplant. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
Cost share is driven by provider/setting. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year Visit limit is combined both across outpatient and other professional visits. Cost share is driven by provider/setting. 20 Visits per year. |
YES | $30.00 |
100.00% |
| Clinical Trials
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
Reconstructive surgery is covered. Reconstructive surgery is performed to correct deformities caused by congenital or developmental abnormalities, illness, injury, or previous therapeutic process, for the purpose of improving bodily function or symptomatology or to create a normal appearance, including surgery performed to restore symmetry following mastectomy. Reconstructive services required due to prior therapeutic process are covered only if the original procedure would have been a covered service under the plan. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
Hospital stay is 48 hours for vaginal delivery and 96 hours for c-section |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year 2 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Diabetes Care Management
|
YES | $60.00 |
100.00% |
| Diabetes Education
Cost share is driven by provider/setting. |
YES | $60.00 |
100.00% |
| Dialysis
Cost share is driven by provider/setting. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Hearing Aids covered In-Network only for ages 1- 18 only. Limit 1 per ear every 48 months with a $3000 cap per ear every 48 months. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Copayment (if applicable) is waived if admitted. |
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 prior authorization is obtained. If authorized out of network, limited to $50,000 per occurrence. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year 1 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
30 day retail supply |
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year 20 visits for Rehabilitation Speech Therapy and 20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy. Applied Behavioral Analysis services are subject to medical necessity and will require an authorization. |
YES | $30.00 |
100.00% |
| Hearing Aids
Benefit is covered for members through age 18. Limited to $3000 per ear every 48 months. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Heart Transplant
Limit: 10000.0 Dollars per Procedure In-Network Transplant Transportation and Lodging $10,000 Maximum benefit limit per Transplant Unrelated Donor Search $30,000 Maximum benefit limit per Transplant. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 120.0 Visit(s) per Year Limit also applies to Physical, Occupational or Speech Therapy when performed as part of Home Health Care Services. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Cost share is driven by provider/setting. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Cost share is driven by provider/setting. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Combined 60 days per year for Inpatient Rehabilitation and Skilled Nursing Facility services. |
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
Cost share is driven by provider/setting. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost share is driven by provider/setting. |
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
30 day retail supply |
YES | $60.00 |
100.00% |
| Nutritional Counseling
Limit: 4.0 Visit(s) per Year Covered only for treatment of morbid obesity. Excluded Nutritional supplements; services, supplies and/or nutritional sustenance products. Limited to 4 visits per year. |
YES | $30.00 |
100.00% |
| Off Label Prescription Drugs
|
YES | $250.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Medically Necessary Orthodontia only |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
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 mobile app or 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 20 visits for Rehabilitation Speech Therapy and 20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy. |
YES | $30.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
30 day retail supply |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
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 mobile app or website. |
YES | $30.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Wigs are limited to 1 (one) per year as needed after cancer treatment.? |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Radiation
Cost share is driven by provider/setting. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Reconstructive surgery is covered. Reconstructive surgery is performed to correct deformities caused by congenital or developmental abnormalities, illness, injury, or previous therapeutic process, for the purpose of improving bodily function or symptomatology or to create a normal appearance, including surgery performed to restore symmetry following mastectomy. Reconstructive services required due to prior therapeutic process are covered only if the original procedure would have been a covered service under the plan. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year 20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy. |
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year 20 visits for Rehabilitation Speech Therapy.? |
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 1 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Year Combined days for Inpatient Rehabilitation and Skilled Nursing Facility services. 60 Days per year. |
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 mobile app or website. |
YES | $60.00 |
100.00% |
| Specialty Drugs
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
Cost share is driven by provider/setting. |
YES | $30.00 |
100.00% |
| Transplant
Limit: 10000.0 Dollars per Procedure In-Network Transplant Transportation and Lodging $10,000 Maximum benefit limit per Transplant Unrelated Donor Search $30,000 Maximum benefit limit per Transplant. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
Additional Cost Share determined based on service received |
YES | $45.00 |
$45.00 |
| Weight Loss Programs
Limit: 4.0 Visit(s) per Year Covered only for treatment of morbid obesity. Excluded Nutritional supplements; services, supplies and/or nutritional sustenance products. Limited to 4 visits per year. |
YES | $60.00 |
100.00% |
| Well Baby Visits and Care
Care provided for birth through age 5. |
YES | No Charge |
100.00% |
| Well Child Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Cost share is driven by provider/setting. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Anthem Gold Pathway HMO 1500/25% Standard Health Insurance Plan Variant 49046GA0410175-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7801851164396751 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| 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 | GAF138 |
| Formulary URL | URL |
| HIOS Product ID | 49046GA041 |
| Import Date | 2023-08-17 20:01:45 |
| 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 | 78.02% |
| Issuer ID | 49046 |
| 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 | GAN002 |
| 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 | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 49046GA0410175-00 |
| Plan Marketing Name | Anthem Gold Pathway X HMO 1500/25% Standard |
| Plan Type | HMO |
| Plan Variant Marketing Name | Anthem Gold Pathway HMO 1500/25% Standard |
| 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 | GAS023 |
| Source Name | SERFF |
| Plan ID | 49046GA0410175 |
| State Code | GA |
| 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 | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| 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 HMO 1500/25% Standard Health Insurance Plan, 49046GA0410175
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Anthem Gold Pathway X HMO 1500/25% Standard, 49046GA0410175 Health Insurance Plan, 49046GA0410175
-
Does Anthem Gold Pathway X HMO 1500/25% Standard Health Insurance Plan, 49046GA0410175 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (49046GA0410175) Health Insurance Plan, Variant (49046GA0410175-00) offer Disease Management Programs?
Does (49046GA0410175) Health Insurance Plan, Variant (49046GA0410175-00) have Out Of Country Coverage?
Does (49046GA0410175) Health Insurance Plan, Variant (49046GA0410175-00) have Out of Service Area Coverage?
Does (49046GA0410175) Health Insurance Plan, Variant (49046GA0410175-00) offer Disease Management Programs?
Does Anthem Gold Pathway HMO 1500/25% Standard Health Insurance Plan, Variant (49046GA0410175-00) offer Disease Management Programs for Asthma?
Does Anthem Gold Pathway HMO 1500/25% Standard Health Insurance Plan, Variant (49046GA0410175-00) offer Disease Management Programs for Heart disease?
Does Anthem Gold Pathway HMO 1500/25% Standard Health Insurance Plan, Variant (49046GA0410175-00) offer Disease Management Programs for Depression?
Does Anthem Gold Pathway HMO 1500/25% Standard Health Insurance Plan, Variant (49046GA0410175-00) offer Disease Management Programs for Diabetes?
Does Anthem Gold Pathway HMO 1500/25% Standard Health Insurance Plan, Variant (49046GA0410175-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Anthem Gold Pathway HMO 1500/25% Standard Health Insurance Plan, Variant (49046GA0410175-00) 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