Anthem Silver Pathway 7250 ($0 Virtual PCP + $0 Select Drugs + Incentives) - 32753MO0950015 Health Insurance Plan
Healthy Alliance Life Co(Anthem BCBS) health insurance plan with the Plan ID 32753MO0950015. The plan is called Anthem Silver Pathway 7250 ($0 Virtual PCP + $0 Select Drugs + Incentives).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 73.10% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 26.90% 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 73.12% (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 26.88% 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 | 32753MO0950015 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Missouri | ||||||||||||||||||
| Health Insurance Issuer | Healthy Alliance Life Co(Anthem BCBS) | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 32753MO0950015-04 | ||||||||||||||||||
| 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 - 32753MO0950015-00 Standard On Exchange Plan - 32753MO0950015-01 Open to Indians below 300% FPL - 32753MO0950015-02 Open to Indians above 300% FPL - 32753MO0950015-03 73% AV Silver Plan - 32753MO0950015-04 |
||||||||||||||||||
| Last Plan Update Date | Thu, 31 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Anthem Silver Pathway 7250 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 32753MO0950015-04
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Limit: 3000.0 Dollars per Episode |
YES | $65.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Applied Behavior Analysis Based Therapies
Limited to members through 18 years of age. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Bone Marrow Testing
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 26.0 Visit(s) per Year Chiropractic Manipulation Therapy visits beyond the 26 visit limit require Prior Authorization from Anthem in order to be covered. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Clinical Trials
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dental Anesthesia
Benefits are provided only for the administration of general anesthesia and for both facility and professional charges occurring in connection with dental services, regardless of age, when prior authorization for an inpatient dental care procedure is approved by us. In addition and as required by law, benefits for the administration of general anesthesia, including facility and professional charges, are provided for the following Members; a Member through the age of four; a Member who is severely disabled and a Member who has a medical or behavioral condition that requires hospitalization or general anesthesia when dental services are provided. |
YES | 30.00% 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 | $65.00 |
100.00% |
| Dialysis
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Emergency Room copay is waived if directly admitted to the hospital. |
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Non-emergency ambulance/transportation out of network is NOT covered, unless prior authorization is obtained from Anthem. Authorized out of network is limited to $50,000 per occurrence. |
YES | 30.00% Coinsurance after deductible |
30.00% 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 shown is for a 30 day supply. |
YES | Tier 1: $5.00 Tier 2: $20.00 |
100.00% |
| Habilitation Services
Limit: 40.0 Visit(s) per Year Rehabilitative Physical Therapy and Occupational Therapy is limited to 20 visits per year. For Covered Services you receive in the office from a Physical Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?For Covered Services you receive in the office from an Occupational Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?All other services are subject to Ded and or Coins. These limitations do not apply to any Autism Spectrum Disorder diagnosis. Cost share is driven by provider setting. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
One hearing aid per ear every 36 months. Limit does not apply to newborn. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 100.0 Visit(s) per Year Benefit includes coverage for Private Duty Nursing in the home and Private Duty Nursing is limited to 82 visits per calendar year. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Cardiac Calcium Screenings are covered with no member cost share. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inherited Metabolic Disorder - PKU
|
YES | Tier 1: 35.00% Coinsurance after deductible Tier 2: 45.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
High Sensitivity C-Reactive Protein Tests are coverd with no member cost share. |
YES | 30.00% 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 | 30.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Limitation of Two office visits per member per Year with a Non-Network licensed provider. |
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Newborn Hearing Screening
|
YES | 30.00% 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: 45.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | 30.00% 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)
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 | $0.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 40.0 Visit(s) per Year Rehabilitative Physical Therapy and Occupational Therapy is limited to 20 visits per year. For Covered Services you receive in the office from a Physical Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?For Covered Services you receive in the office from an Occupational Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?All other services are subject to Ded and or Coins. These limitations do not apply to any Autism Spectrum Disorder diagnosis. Cost share is driven by provider setting. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Cost share shown is for a 30 day supply. |
YES | Tier 1: $40.00 Tier 2: $55.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
This plan offers a Well-being Coach to encourage healthier habits and behavior changes to reduce the risk and costs associated with chronic conditions. This program will help modify behaviors associated with obesity, tobacco use, poor nutrition, inactivity, poor sleep and stress. 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. Immunizations prior to 6th birthday covered in full. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Cardiologist office visits will follow this cost share. 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 | $0.00 |
100.00% |
| Private-Duty Nursing
Limit: 82.0 Visit(s) per Year Benefit includes coverage for Private Duty Nursing in the home and Private Duty Nursing is limited to 82 visits per calendar year. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
Benefits include the purchase, fitting, adjustments, repairs and replacements. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year Rehabilitative Physical Therapy and Occupational Therapy is limited to 20 visits per year. For Covered Services you receive in the office from a Physical Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?For Covered Services you receive in the office from an Occupational Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?All other services are subject to Ded and or Coins. These limitations do not apply to any Autism Spectrum Disorder diagnosis. Cost share is driven by provider setting. |
YES | $0.00 |
100.00% |
| Rehabilitative Speech Therapy
|
YES | 30.00% 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 Year |
YES | No Charge |
100.00% |
| Routine Foot Care
Coverage is available if Medically Necessary Services |
YES | $65.00 |
100.00% |
| Skilled Nursing Facility
Limit: 150.0 Days per Year Limited to 150 combined days per calendar year for Physical Medicine, Rehabilitation and Skilled Nursing Facility services. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Cardiologist office visits will follow the Primary Care Visit to Treat and Injury or Illness cost share. 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 | $65.00 |
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 | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Limitation of Two office visits per member per Year with a Non-Network licensed provider. |
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Transplant
Includes coverage for travel/lodging as approved by the plan ($10,000 per transplant). Donor search charges are limited to 10 best matched donors identified by an authorized registry. |
YES | 30.00% 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. Covered 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 | 30.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $75.00 |
$75.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Carotid Intimal Medical Thickness Tests are covered with no member cost share. |
YES | 30.00% Coinsurance after deductible |
100.00% |
Anthem Silver Pathway X 3550 ($0 Virtual PCP + $0 Select Drugs + Incentives) S04 Health Insurance Plan Variant 32753MO0950015-04 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7312043284631179 |
| 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 | 73% AV Level Silver 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 | 40% |
| Formulary ID | MOF510 |
| Formulary URL | URL |
| HIOS Product ID | 32753MO095 |
| Import Date | 2024-10-31 01:01:26 |
| 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 | 73.10% |
| Issuer ID | 32753 |
| 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 | MON001 |
| 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 | Standard Bluecard PPO Network |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 32753MO0950015-04 |
| Plan Marketing Name | Anthem Silver Pathway 7250 ($0 Virtual PCP + $0 Select Drugs + Incentives) |
| Plan Type | EPO |
| Plan Variant Marketing Name | Anthem Silver Pathway X 3550 ($0 Virtual PCP + $0 Select Drugs + Incentives) S04 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,700 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $3,550 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,300 |
| SBC Scenario, Having Diabetes, Deductible | $100 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,100 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 60% |
| Service Area ID | MOS001 |
| Source Name | HIOS |
| Plan ID | 32753MO0950015 |
| State Code | MO |
| 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 | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $7100 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3550 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,550 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $7100 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $3550 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $3,550 |
| 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 | $14700 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7350 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,350 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $14700 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $7350 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $7,350 |
| 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 Pathway 7250 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 32753MO0950015
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Anthem Silver Pathway 7250 ($0 Virtual PCP + $0 Select Drugs + Incentives), 32753MO0950015 Health Insurance Plan, 32753MO0950015
-
Does Anthem Silver Pathway 7250 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 32753MO0950015 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (32753MO0950015) Health Insurance Plan, Variant (32753MO0950015-04) offer Disease Management Programs?
Does (32753MO0950015) Health Insurance Plan, Variant (32753MO0950015-04) have Out Of Country Coverage?
Does (32753MO0950015) Health Insurance Plan, Variant (32753MO0950015-04) have Out of Service Area Coverage?
Does (32753MO0950015) Health Insurance Plan, Variant (32753MO0950015-04) offer Disease Management Programs?
Does Anthem Silver Pathway X 3550 ($0 Virtual PCP + $0 Select Drugs + Incentives) S04 Health Insurance Plan, Variant (32753MO0950015-04) offer Disease Management Programs for Asthma?
Does Anthem Silver Pathway X 3550 ($0 Virtual PCP + $0 Select Drugs + Incentives) S04 Health Insurance Plan, Variant (32753MO0950015-04) offer Disease Management Programs for Heart disease?
Does Anthem Silver Pathway X 3550 ($0 Virtual PCP + $0 Select Drugs + Incentives) S04 Health Insurance Plan, Variant (32753MO0950015-04) offer Disease Management Programs for Depression?
Does Anthem Silver Pathway X 3550 ($0 Virtual PCP + $0 Select Drugs + Incentives) S04 Health Insurance Plan, Variant (32753MO0950015-04) offer Disease Management Programs for Diabetes?
Does Anthem Silver Pathway X 3550 ($0 Virtual PCP + $0 Select Drugs + Incentives) S04 Health Insurance Plan, Variant (32753MO0950015-04) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Anthem Silver Pathway X 3550 ($0 Virtual PCP + $0 Select Drugs + Incentives) S04 Health Insurance Plan, Variant (32753MO0950015-04) 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