Wellpoint Essential Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives) - 47501TX0040010 Health Insurance Plan
Wellpoint Insurance Company health insurance plan with the Plan ID 47501TX0040010. The plan is called Wellpoint Essential Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.15% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.85% 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 69.90% (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 30.10% 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 | 47501TX0040010 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 47501TX0040010-00 | ||||||||||||||||||
| 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 | Standard Off Exchange Plan - 47501TX0040010-00 Standard On Exchange Plan - 47501TX0040010-01 Open to Indians below 300% FPL - 47501TX0040010-02 Open to Indians above 300% FPL - 47501TX0040010-03 73% AV Silver Plan - 47501TX0040010-04 |
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| 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 Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 47501TX0040010-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $80.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
Additional EHB Benefit |
YES | 40.00% |
100.00% |
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | $500.00 Copay after deductible, 40.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $80.00 |
100.00% |
| Dialysis
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Continuous glucose monitors and related supplies are covered under DME. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | $500.00 Copay after deductible, 40.00% Coinsurance after deductible |
$500.00 Copay after deductible, 40.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
NonNetwork nonemergency ambulance services are subject to the same Cost Share as Network services up to $50,000 per trip. |
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance 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 | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Retail Pharmacy is limited to a 30-day supply per Prescription. |
YES | Tier 1: $5.00 Tier 2: $20.00 |
100.00% |
| Habilitation Services
Limit: 35.0 Visit(s) per Year Limit is combined for rehabilitative and habilitative physical therapy, occupational therapy and speech therapy. Services submitted with an Autism diagnosis are unlimited for physical, occupational and speech therapy. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Services to restore loss of or correct an impaired speech or hearing function with hearing aids are covered as any other sickness. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Limited to a maximum of 60 visits per Member per Calendar Year |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $500.00 Copay per Stay after deductible, 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Services submitted with an Autism diagnosis are unlimited for physical, occupational and speech therapy. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
Additional EHB Benefit |
YES | 50.00% |
100.00% |
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | $500.00 Copay per Stay after deductible, 40.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Non-Preferred Brand Drugs
Retail Pharmacy is limited to a 30-day supply per Prescription. |
YES | Tier 1: 35.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services. 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 | $25.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Limit is combined for rehabilitative physical therapy and manipulation therapy. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Retail Pharmacy is limited to a 30-day supply per Prescription. |
YES | Tier 1: $40.00 Tier 2: $55.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services. 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 | $25.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | $500.00 Copay after deductible, 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Year Limit is combined for rehabilitative and habilitative physical therapy, occupational therapy and speech therapy. Limit is combined for rehabilitative physical therapy and manipulation therapy. Services submitted with an Autism diagnosis are unlimited for physical, occupational and speech therapy. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Year Limit is combined for rehabilitative and habilitative physical therapy, occupational therapy and speech therapy. Services submitted with an Autism diagnosis are unlimited for physical, occupational and speech therapy. |
YES | 20.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
|
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
|
YES | $20.00 |
100.00% |
| 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 | No Charge |
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 | 20.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $80.00 |
100.00% |
| Specialty Drugs
Specialty Drugs must be purchased from the Pharmacy Benefits Manager?s Specialty Pharmacy and are limited to a 30-day supply. |
YES | Tier 1: 50.00% Coinsurance after deductible Tier 2: 60.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $500.00 Copay per Stay after deductible, 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Transplant
Transportation and lodging are not covered out of network. Donor search charges are limited to 10 best matched donors per transplant, identified by an authorized registry. |
YES | $500.00 Copay after deductible, 40.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $60.00 |
$60.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Wellpoint Essential Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 47501TX0040010-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.698966645762884 |
| 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 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 | 0.9846676644496609 |
| First Tier Utilization | 50% |
| Formulary ID | TXF516 |
| 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 Actuarial Value | 70.15% |
| 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 | Silver |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | TXN003 |
| 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) | 47501TX0040010-00 |
| Plan Marketing Name | Wellpoint Essential Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives) |
| Plan Type | HMO |
| Plan Variant Marketing Name | Wellpoint Essential Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,200 |
| 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 | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,500 |
| 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 | $2,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 50% |
| Service Area ID | TXS001 |
| Source Name | HIOS |
| Plan ID | 47501TX0040010 |
| 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 | 20.00% |
| 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 | 20.00% |
| 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 | $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 Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 47501TX0040010
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Wellpoint Essential Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives), 47501TX0040010 Health Insurance Plan, 47501TX0040010
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Does Wellpoint Essential Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 47501TX0040010 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (47501TX0040010) Health Insurance Plan, Variant (47501TX0040010-00) offer Disease Management Programs?
Does (47501TX0040010) Health Insurance Plan, Variant (47501TX0040010-00) have Out Of Country Coverage?
Does (47501TX0040010) Health Insurance Plan, Variant (47501TX0040010-00) have Out of Service Area Coverage?
Does (47501TX0040010) Health Insurance Plan, Variant (47501TX0040010-00) offer Disease Management Programs?
Does Wellpoint Essential Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (47501TX0040010-00) offer Disease Management Programs for Asthma?
Does Wellpoint Essential Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (47501TX0040010-00) offer Disease Management Programs for Heart disease?
Does Wellpoint Essential Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (47501TX0040010-00) offer Disease Management Programs for Depression?
Does Wellpoint Essential Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (47501TX0040010-00) offer Disease Management Programs for Diabetes?
Does Wellpoint Essential Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (47501TX0040010-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Wellpoint Essential Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (47501TX0040010-00) 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