Wellpoint Essential Silver POS 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) - 47501TX0030001 Health Insurance Plan

Wellpoint Insurance Company health insurance plan with the Plan ID 47501TX0030001. The plan is called Wellpoint Essential Silver POS 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives).

Based on the data of Health Plan Issuer, this plan has an actuarial value of 94.14% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 5.86% 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 94.14% (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 5.86% 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 47501TX0030001
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 47501TX0030001-06
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).

Providers Texas All US States
All 18931 20296
PCP 3018 3190
Allergy 23 23
OB/GYN 203 218
Dentists 12 14
Available Variants of the Health Plan

Standard Off Exchange Plan - 47501TX0030001-00

Standard On Exchange Plan - 47501TX0030001-01

Open to Indians below 300% FPL - 47501TX0030001-02

Open to Indians above 300% FPL - 47501TX0030001-03

73% AV Silver Plan - 47501TX0030001-04

87% AV Silver Plan - 47501TX0030001-05

94% AV Silver Plan - 47501TX0030001-06

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 POS 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 47501TX0030001-06

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

$10.00

50.00% Coinsurance after deductible
Acupuncture
NO
Allergy Testing
YES

25.00%

50.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

25.00%

50.00% Coinsurance after deductible
Chiropractic Care

Limit: 35.0 Visit(s) per Year

YES

$0.00

50.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

25.00%

50.00% Coinsurance after deductible
Dental Check-Up for Children
NO
Diabetes Education
YES

$10.00

50.00% Coinsurance after deductible
Dialysis
YES

25.00%

50.00% Coinsurance after deductible
Durable Medical Equipment

Continuous glucose monitors and related supplies are covered under DME.

YES

25.00%

50.00% Coinsurance after deductible
Emergency Room Services
YES

25.00%

25.00%
Emergency Transportation/Ambulance

NonNetwork nonemergency ambulance services are subject to the same Cost Share as Network services up to $50,000 per trip.

YES

25.00%

25.00%
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

$0.00, 70.00%
Gender Affirming Care
NO
Generic Drugs

Retail Pharmacy is limited to a 30-day supply per Prescription.

YES

$0.00

50.00% Coinsurance after deductible
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

$0.00

50.00% Coinsurance after deductible
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

25.00%

50.00% Coinsurance after deductible
Home Health Care Services

Limit: 60.0 Visit(s) per Year

Limited to a maximum of 60 visits per Member per Calendar Year

YES

25.00%

50.00% Coinsurance after deductible
Hospice Services
YES

25.00%

50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)
YES

25.00%

50.00% Coinsurance after deductible
Infertility Treatment
NO
Infusion Therapy
YES

25.00%

50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

25.00%

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

25.00%

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services

Services submitted with an Autism diagnosis are unlimited for physical, occupational and speech therapy.

YES

25.00%

50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

25.00%

50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services

The cost sharing that displays applies to outpatient office visits. Similar services provided in an Outpatient Hospital setting may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

YES

$0.00

50.00% Coinsurance after deductible
Non-Preferred Brand Drugs

Retail Pharmacy is limited to a 30-day supply per Prescription.

YES

$50.00

50.00% Coinsurance after deductible
Nutritional Counseling
YES

$0.00

50.00% Coinsurance after deductible
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

$0.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

25.00%

50.00% Coinsurance after deductible
Outpatient Rehabilitation Services

Limit: 35.0 Visit(s) per Year

Limit is combined for rehabilitative physical therapy and manipulation therapy.

YES

$0.00

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

25.00%

50.00% Coinsurance after deductible
Preferred Brand Drugs

Retail Pharmacy is limited to a 30-day supply per Prescription.

YES

$15.00

50.00% Coinsurance after deductible
Prenatal and Postnatal Care
YES

25.00%

50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

0.00%

50.00% Coinsurance after deductible
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

$0.00

50.00% Coinsurance after deductible
Private-Duty Nursing
NO
Prosthetic Devices
YES

25.00%

50.00% Coinsurance after deductible
Radiation
YES

25.00%

50.00% Coinsurance after deductible
Reconstructive Surgery
YES

25.00%

50.00% Coinsurance after deductible
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

$0.00

50.00% Coinsurance after deductible
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

$0.00

50.00% Coinsurance after deductible
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

No Charge

$0.00, 70.00%
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

25.00%

50.00% Coinsurance after deductible
Specialist Visit
YES

$10.00

50.00% Coinsurance after deductible
Specialty Drugs

Specialty Drugs must be purchased from the Pharmacy Benefits Manager?s Specialty Pharmacy and are limited to a 30-day supply.

YES

$150.00

100.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
YES

25.00%

50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services

The cost sharing that displays applies to outpatient office visits. Similar services provided in an Outpatient Hospital setting may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

YES

$0.00

50.00% Coinsurance after deductible
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

25.00%

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
YES

25.00%

50.00% Coinsurance after deductible
Urgent Care Centers or Facilities
YES

$5.00

$5.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
YES

25.00%

50.00% Coinsurance after deductible

Wellpoint Essential Silver POS Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) S06 Health Insurance Plan Variant 47501TX0030001-06 Attributes

Plan Attribute Value
AV Calculator Output Number 0.9414114984395309
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 94% AV Level Silver 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 TXF524
Formulary URL URL
HIOS Product ID 47501TX003
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 94.14%
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 No
National Network No
Network ID TXN001
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) 47501TX0030001-06
Plan Marketing Name Wellpoint Essential Silver POS 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives)
Plan Type POS
Plan Variant Marketing Name Wellpoint Essential Silver POS Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) S06
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,000
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $30
SBC Scenario, Having Diabetes, Copayment $600
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $500
SBC Scenario, Treatment of a Simple Fracture, Copayment $30
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID TXS001
Source Name HIOS
Plan ID 47501TX0030001
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 25.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $0
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $40000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $20000 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $20,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $4000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $2000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $2,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $1000000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $1000000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $1,000,000
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 POS 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 47501TX0030001

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Wellpoint Essential Silver POS 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives), 47501TX0030001 Health Insurance Plan, 47501TX0030001

  • Does Wellpoint Essential Silver POS 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 47501TX0030001 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (47501TX0030001) Health Insurance Plan, Variant (47501TX0030001-06) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management

    Does (47501TX0030001) Health Insurance Plan, Variant (47501TX0030001-06) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan). Details: Urgent/Emergency Coverage Only

    Does (47501TX0030001) Health Insurance Plan, Variant (47501TX0030001-06) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

    Does (47501TX0030001) Health Insurance Plan, Variant (47501TX0030001-06) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management

    Does Wellpoint Essential Silver POS Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) S06 Health Insurance Plan, Variant (47501TX0030001-06) offer Disease Management Programs for Asthma?

    Yes, the Wellpoint Essential Silver POS Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) S06 Health Insurance Plan Variant 47501TX0030001-06 offers Disease Management Program for Asthma.

    Does Wellpoint Essential Silver POS Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) S06 Health Insurance Plan, Variant (47501TX0030001-06) offer Disease Management Programs for Heart disease?

    Yes, the Wellpoint Essential Silver POS Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) S06 Health Insurance Plan Variant 47501TX0030001-06 offers Disease Management Program for Heart disease.

    Does Wellpoint Essential Silver POS Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) S06 Health Insurance Plan, Variant (47501TX0030001-06) offer Disease Management Programs for Depression?

    Yes, the Wellpoint Essential Silver POS Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) S06 Health Insurance Plan Variant 47501TX0030001-06 offers Disease Management Program for Depression.

    Does Wellpoint Essential Silver POS Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) S06 Health Insurance Plan, Variant (47501TX0030001-06) offer Disease Management Programs for Diabetes?

    Yes, the Wellpoint Essential Silver POS Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) S06 Health Insurance Plan Variant 47501TX0030001-06 offers Disease Management Program for Diabetes.

    Does Wellpoint Essential Silver POS Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) S06 Health Insurance Plan, Variant (47501TX0030001-06) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Wellpoint Essential Silver POS Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) S06 Health Insurance Plan Variant 47501TX0030001-06 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Wellpoint Essential Silver POS Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) S06 Health Insurance Plan, Variant (47501TX0030001-06) offer Disease Management Programs for Low back pain?

    Yes, the Wellpoint Essential Silver POS Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) S06 Health Insurance Plan Variant 47501TX0030001-06 offers Disease Management Program 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