Wellpoint Essential Catastrophic 9200 ($0 Virtual PCP + $0 Select Drugs + Incentives) - 47501TX0040006 Health Insurance Plan
Wellpoint Insurance Company health insurance plan with the Plan ID 47501TX0040006. The plan is called Wellpoint Essential Catastrophic 9200 ($0 Virtual PCP + $0 Select Drugs + Incentives).
| Health Insurance Plan ID | 47501TX0040006 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | Wellpoint Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 47501TX0040006-00 | ||||||||||||||||||
| 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). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Thu, 17 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Wellpoint Essential Catastrophic 9200 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 47501TX0040006-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | No Charge after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
YES | No Charge after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section. |
YES | No Charge after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge after deductible |
100.00% |
| Dialysis
|
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
|
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Frames and lenses or contat lenses are covered once per benefit period. Limit is comnbined in network and out of network. |
YES | $0.00 Copay after deductible |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Habilitation Services
Limit: 35.0 Visit(s) per Year Habilitative and rehabilitative limits cannot be combined for plans issued or renewed on or after January 1, 2017. Habilitation services includes autism services, and the benchmark plan does not impose age or maximums on autism coverage. |
YES | No Charge after deductible |
100.00% |
| Hearing Aids
To restore or correction of impaired speech or hearing loss. |
YES | No Charge after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Hospice Services
Preauthorization is required. |
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required. |
YES | No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | No Charge 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
Preauthorization is required. |
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Preauthorization is required. |
YES | No Charge after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | No Charge after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $40.00, No Charge after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
YES | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
First 3 Primary Care office visits combined are not subject to the deductible.? Additional office visits are subject to deductible and coinsurance. 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 | $40.00, No Charge after deductible |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Medically necessary foot orthotics are not subject to a calendar year maximum. |
YES | No Charge after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed. |
YES | No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
|
YES | No Charge after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Eye exams are covered once per benefit period. Limit is combined in network and out of network for the exam. |
YES | $0.00 Copay after deductible |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 25.0 Days per Year Limited to a maximum of 25 days per Member, per Calendar Year |
YES | No Charge after deductible |
100.00% |
| Specialist Visit
|
YES | No Charge after deductible |
100.00% |
| Specialty Drugs
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Preauthorization is required. |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Certain services require preauthorization. |
YES | No Charge after deductible |
100.00% |
| Transplant
Preauthorization is required. |
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Though state law only mandates coverage for temporomandibular joint (TMJ) disorders for large group plans and HMOs, the benchmark plan covers TMJ. Therefore, it is considered part of the EHB package for Texas. |
YES | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
No Charge after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
100.00% |
Wellpoint Essential Catastrophic 9200 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 47501TX0040006-00 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 3 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Catastrophic Off 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 | 50% |
| Formulary ID | TXF501 |
| Formulary URL | URL |
| HIOS Product ID | 47501TX004 |
| Import Date | 2024-10-17 01:02:25 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 47501 |
| Issuer Marketplace Marketing Name | WellPoint |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Catastrophic |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | TXN002 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Urgent/Emergency Coverage Only |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 47501TX0040006-00 |
| Plan Marketing Name | Wellpoint Essential Catastrophic 9200 ($0 Virtual PCP + $0 Select Drugs + Incentives) |
| Plan Type | HMO |
| Plan Variant Marketing Name | Wellpoint Essential Catastrophic 9200 ($0 Virtual PCP + $0 Select Drugs + 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 | $9,200 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $100 |
| SBC Scenario, Having Diabetes, Deductible | $5,200 |
| 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 | 50% |
| Service Area ID | TXS001 |
| Source Name | HIOS |
| Plan ID | 47501TX0040006 |
| State Code | TX |
| 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 | $18400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $9200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $9,200 |
| 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 | $18400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $9200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $9,200 |
| 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 | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,200 |
| 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 Wellpoint Essential Catastrophic 9200 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 47501TX0040006
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Wellpoint Essential Catastrophic 9200 ($0 Virtual PCP + $0 Select Drugs + Incentives), 47501TX0040006 Health Insurance Plan, 47501TX0040006
-
Does Wellpoint Essential Catastrophic 9200 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 47501TX0040006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (47501TX0040006) Health Insurance Plan, Variant (47501TX0040006-00) offer Disease Management Programs?
Does (47501TX0040006) Health Insurance Plan, Variant (47501TX0040006-00) have Out Of Country Coverage?
Does (47501TX0040006) Health Insurance Plan, Variant (47501TX0040006-00) have Out of Service Area Coverage?
Does (47501TX0040006) Health Insurance Plan, Variant (47501TX0040006-00) offer Disease Management Programs?
Does Wellpoint Essential Catastrophic 9200 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (47501TX0040006-00) offer Disease Management Programs for Asthma?
Does Wellpoint Essential Catastrophic 9200 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (47501TX0040006-00) offer Disease Management Programs for Heart disease?
Does Wellpoint Essential Catastrophic 9200 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (47501TX0040006-00) offer Disease Management Programs for Depression?
Does Wellpoint Essential Catastrophic 9200 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (47501TX0040006-00) offer Disease Management Programs for Diabetes?
Does Wellpoint Essential Catastrophic 9200 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (47501TX0040006-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Wellpoint Essential Catastrophic 9200 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (47501TX0040006-00) 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