Anthem Silver Essential 3500 HSA (+ Incentives) - 17575IN0700062 Health Insurance Plan
Anthem Ins Companies Inc(Anthem BCBS) health insurance plan with the Plan ID 17575IN0700062. The plan is called Anthem Silver Essential 3500 HSA (+ Incentives).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 30.00% 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 70.19% (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 29.81% 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 | 17575IN0700062 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 17575IN0700062-01 | ||||||||||||||||||
| 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 - 17575IN0700062-00 Standard On Exchange Plan - 17575IN0700062-01 Open to Indians below 300% FPL - 17575IN0700062-02 Open to Indians above 300% FPL - 17575IN0700062-03 73% AV Silver Plan - 17575IN0700062-04 |
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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 Silver Essential 3500 HSA (+ Incentives) Health Insurance Plan, 17575IN0700062-01
| 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 | 15.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 15.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 15.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Year |
YES | 15.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | $500.00 Copay after deductible, 50.00% Coinsurance 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 | 15.00% Coinsurance 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 | 15.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 15.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Wigs limited to the first one following cancer treatment. |
YES | 15.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | $300.00 Copay after deductible, 15.00% Coinsurance after deductible |
$300.00 Copay after deductible, 15.00% 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 | 15.00% Coinsurance after deductible |
15.00% Coinsurance 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: $10.00 Copay after deductible Tier 2: $25.00 Copay 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 | 15.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Year |
YES | 15.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 15.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $300.00 Copay after deductible, 50.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 15.00% Coinsurance 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 | $500.00 Copay per Stay after deductible, 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 15.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 15.00% 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 |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | $500.00 Copay per Stay after deductible, 50.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost share determined by services rendered. |
YES | 15.00% Coinsurance after deductible |
100.00% |
| Non-Preferred Brand Drugs
Cost share shown is for a 30 day supply. |
YES | Tier 1: 35.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Covered under preventive guidelines and for diabetes. Cost share is driven by provider/setting. |
YES | 15.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Deductible/coinsurance 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 | 15.00% Coinsurance after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 15.00% Coinsurance 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 | 15.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 15.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Cost share shown is for a 30 day supply. |
YES | Tier 1: $40.00 Copay after deductible Tier 2: $55.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | 15.00% Coinsurance 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/coinsurance 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 | 15.00% Coinsurance 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 | 15.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
|
YES | 15.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 15.00% Coinsurance 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 | $500.00 Copay after deductible, 50.00% Coinsurance 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 | 15.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Cost share determined by services rendered. |
YES | 15.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| 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 | 15.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Deductible/coinsurance 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 | 15.00% Coinsurance after deductible |
100.00% |
| Specialty Drugs
Cost share shown is for a 30 day supply. |
YES | Tier 1: 40.00% Coinsurance after deductible Tier 2: 55.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $500.00 Copay per Stay after deductible, 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Cost share determined by services rendered. |
YES | 15.00% Coinsurance 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 | $500.00 Copay after deductible, 50.00% Coinsurance 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 | 15.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | 15.00% Coinsurance after deductible |
15.00% Coinsurance 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 | 15.00% Coinsurance after deductible |
100.00% |
Anthem Silver Essential 3500 HSA (+ Incentives) Health Insurance Plan Variant 17575IN0700062-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7018921146736371 |
| 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 Silver 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 | 1.0 |
| First Tier Utilization | 71% |
| Formulary ID | INF503 |
| 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 | Yes |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 70.00% |
| 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 | Silver |
| 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) | 17575IN0700062-01 |
| Plan Marketing Name | Anthem Silver Essential 3500 HSA (+ Incentives) |
| Plan Type | HMO |
| Plan Variant Marketing Name | Anthem Silver Essential 3500 HSA (+ Incentives) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,800 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $3,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $20 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| SBC Scenario, Having Diabetes, Deductible | $3,500 |
| 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 | 17575IN0700062 |
| 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 | 15.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $7000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,500 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 15.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $7000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $3500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $3,500 |
| 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 | $14800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,400 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $14800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $7400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $7,400 |
| 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 Silver Essential 3500 HSA (+ Incentives) Health Insurance Plan, 17575IN0700062
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Anthem Silver Essential 3500 HSA (+ Incentives), 17575IN0700062 Health Insurance Plan, 17575IN0700062
-
Does Anthem Silver Essential 3500 HSA (+ Incentives) Health Insurance Plan, 17575IN0700062 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (17575IN0700062) Health Insurance Plan, Variant (17575IN0700062-01) offer Disease Management Programs?
Does (17575IN0700062) Health Insurance Plan, Variant (17575IN0700062-01) have Out Of Country Coverage?
Does (17575IN0700062) Health Insurance Plan, Variant (17575IN0700062-01) have Out of Service Area Coverage?
Does (17575IN0700062) Health Insurance Plan, Variant (17575IN0700062-01) offer Disease Management Programs?
Does Anthem Silver Essential 3500 HSA (+ Incentives) Health Insurance Plan, Variant (17575IN0700062-01) offer Disease Management Programs for Asthma?
Does Anthem Silver Essential 3500 HSA (+ Incentives) Health Insurance Plan, Variant (17575IN0700062-01) offer Disease Management Programs for Heart disease?
Does Anthem Silver Essential 3500 HSA (+ Incentives) Health Insurance Plan, Variant (17575IN0700062-01) offer Disease Management Programs for Depression?
Does Anthem Silver Essential 3500 HSA (+ Incentives) Health Insurance Plan, Variant (17575IN0700062-01) offer Disease Management Programs for Diabetes?
Does Anthem Silver Essential 3500 HSA (+ Incentives) Health Insurance Plan, Variant (17575IN0700062-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Anthem Silver Essential 3500 HSA (+ Incentives) Health Insurance Plan, Variant (17575IN0700062-01) 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