Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) - 17575IN0760005 Health Insurance Plan

Anthem Ins Companies Inc(Anthem BCBS) health insurance plan with the Plan ID 17575IN0760005. The plan is called Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives).

Based on the data of Health Plan Issuer, this plan has an actuarial value of 62.26% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 37.74% 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 62.38% (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 37.62% 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 17575IN0760005
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 17575IN0760005-00
Provider Network(s) PARTICIPATING
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT).

Providers Indiana All US States
All 13253 106447
PCP 2149 3590
Allergy 4 8
OB/GYN 82 217
Dentists 856 57585
Available Variants of the Health Plan

Standard Off Exchange Plan - 17575IN0760005-00

Standard On Exchange Plan - 17575IN0760005-01

Open to Indians below 300% FPL - 17575IN0760005-02

Open to Indians above 300% FPL - 17575IN0760005-03

Last Plan Update Date Sat, 02 Nov 2024 00:00 GMT
Last Import Date Tue, 03 Dec 2024 06:24 GMT

Benefits of Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 17575IN0760005-00

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

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Acupuncture
NO
Allergy Testing
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chemotherapy
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Chiropractic Care

Limit: 12.0 Visit(s) per Year

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

50.00% Coinsurance after deductible

60.00% Coinsurance after deductible
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

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Year

YES

No Charge after deductible

30.00% Coinsurance after deductible
Diabetes Education
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Dialysis
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Durable Medical Equipment

Wigs limited to the first one following cancer treatment.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
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

Non-emergency ambulance/transportation out of network is not covered unless authorized. Authorized out of network is limited to $50,000 per trip.

YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Limited reimbursement up to maximum allowable for all services. Eye glasses are covered once per benefit period. Limit is combined in network and out of network across all outpatient settings.

YES

No Charge

$0.00
Gender Affirming Care
NO
Generic 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

60.00% Coinsurance after deductible
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

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Hearing Aids
NO
Home Health Care Services

Limit: 100.0 Visit(s) per Year

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Hospice Services
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)
YES

$500.00 Copay after deductible, 50.00% Coinsurance after deductible

$1000.00 Copay after deductible, 60.00% Coinsurance after deductible
Infertility Treatment
NO
Infusion Therapy
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
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

50.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
YES

50.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services

Cost share determined by services rendered.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Non-Preferred Brand 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

60.00% Coinsurance after deductible
Nutritional Counseling

Covered under preventive guidelines and for diabetes. Cost share is driven by provider/setting.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)

First 3 visits subject to copay. Visits 4+ 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

$50.00, 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
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

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Preferred Brand 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

60.00% Coinsurance after deductible
Prenatal and Postnatal Care
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
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

60.00% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness

First 3 visits subject to copay. Visits 4+ 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

$50.00, 40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
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

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Prosthetic Devices
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Radiation
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
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

50.00% Coinsurance after deductible

60.00% Coinsurance after deductible
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

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Cost share determined by services rendered.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Benefit Period

Limited reimbursement up to maximum allowable for all services. Eye exams are covered once per benefit period. Limit is combined in network and out of network across all outpatient settings.

YES

No Charge

$0.00
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 90.0 Days per Year

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Specialist Visit

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

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
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

60.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
YES

50.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services

Cost share determined by services rendered.

YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
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

50.00% Coinsurance after deductible

60.00% Coinsurance after deductible
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

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Urgent Care Centers or Facilities
YES

$90.00

$90.00
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

60.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
YES

40.00% Coinsurance after deductible

60.00% Coinsurance after deductible

Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 17575IN0760005-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.6237967205707701
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 Bronze 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 71%
Formulary ID INF517
Formulary URL URL
HIOS Product ID 17575IN076
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 No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 62.26%
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 Expanded Bronze
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) 17575IN0760005-00
Plan Marketing Name Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives)
Plan Type POS
Plan Variant Marketing Name Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,500
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $5,500
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 29%
Service Area ID INS021
Source Name HIOS
Plan ID 17575IN0760005
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 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $11000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,500
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $11000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $5500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $5,500
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $33000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $16500 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $16,500
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 $55200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $27600 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $27,600
Unique Plan Design Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 17575IN0760005

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

Frequently Asked Questions(FAQ) about Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives), 17575IN0760005 Health Insurance Plan, 17575IN0760005

  • Does Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 17575IN0760005 support Mail Ordering?

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

  • Does (17575IN0760005) Health Insurance Plan, Variant (17575IN0760005-00) 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 (17575IN0760005) Health Insurance Plan, Variant (17575IN0760005-00) 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 (17575IN0760005) Health Insurance Plan, Variant (17575IN0760005-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: TRAD/PAR network

    Does (17575IN0760005) Health Insurance Plan, Variant (17575IN0760005-00) 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 Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (17575IN0760005-00) offer Disease Management Programs for Asthma?

    Yes, the Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 17575IN0760005-00 offers Disease Management Program for Asthma.

    Does Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (17575IN0760005-00) offer Disease Management Programs for Heart disease?

    Yes, the Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 17575IN0760005-00 offers Disease Management Program for Heart disease.

    Does Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (17575IN0760005-00) offer Disease Management Programs for Depression?

    Yes, the Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 17575IN0760005-00 offers Disease Management Program for Depression.

    Does Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (17575IN0760005-00) offer Disease Management Programs for Diabetes?

    Yes, the Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 17575IN0760005-00 offers Disease Management Program for Diabetes.

    Does Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (17575IN0760005-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 17575IN0760005-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (17575IN0760005-00) offer Disease Management Programs for Low back pain?

    Yes, the Anthem Bronze Essential POS 5500 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 17575IN0760005-00 offers Disease Management Program for Low back pain.

 

Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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