Wisconsin health plan · 2025

Anthem Dental Family Preventive · 90028WI0420006

Blue Cross Blue Shield of Wisconsin (PPO and out of network POS) offers this marketplace plan (Plan ID 90028WI0420006). Use the modules below to compare premiums, coverage structure, provider access, and formulary context against alternative options in the same market.

Metal level: Low Plan type: PPO CSR: Standard Low Off Exchange Plan Issuer: Blue Cross Blue Shield of Wisconsin (PPO and out of network POS)
Telehealth Data pending HSA eligible Check with issuer Dental Adult/Child Vision Not listed
Pay / Manage Plan View issuer site

2025 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 10 Mar 2026 06:40 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$10 – $24

Before subsidies

Estimate after subsidies

Deductible

N/A

N/A

See deductible details

Max out-of-pocket

N/A

N/A

Review MOOP rules

Office visits

Primary care See benefits
Specialist See benefits

Drug tiers

Generic See drug coverage
Preferred brand See drug coverage

View formulary tiers

$10 / mo before subsidies

≈ $114 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$43 / mo before subsidies

≈ $512 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$66 / mo before subsidies

≈ $795 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$19 / mo before subsidies

≈ $229 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits
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Enrollment guidance

Stay on top of 2025 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in Wisconsin). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • Standard Low Off Exchange Plan plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 90028WI0420006
Coverage year 2025
State Wisconsin
Issuer Blue Cross Blue Shield of Wisconsin (PPO and out of network POS)
Marketing materials View marketing kit
Variant ID 90028WI0420006-00
Available variants

Standard Off Exchange Plan · 90028WI0420006-00

Standard On Exchange Plan · 90028WI0420006-01
Last plan update Thu, 15 Aug 2024 00:00 GMT
Last HealthPorta import Tue, 10 Mar 2026 06:40 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 10 Mar 2026 06:40 GMT).

All providers in Wisconsin N/A
PCPs in Wisconsin N/A
Telehealth support Data pending
Nationwide providers N/A
N/A doctors statewide N/A PCPs N/A OB/GYN

Provider network(s)

['WIN001']

Providers Wisconsin All US states
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A

Drug coverage overview

0 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Prior authorization Drugs
Required 0
Not Required 0
Step therapy Drugs
Required 0
Not Required 0
Quantity limits Drugs
Has Limit 0
No Limit 0

Customer highlights

What stands out for members

  • Issuer: Blue Cross Blue Shield of Wisconsin (PPO and out of network POS) · Plan ID 90028WI0420006 · 2025 filing.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 90028WI0420006-00 (Standard Off Exchange Plan) currently displayed.
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Benefits

Covered services & limitations

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Major Dental Care - Child

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

Coverage details pending

nan

Exclusions: nan

Basic Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Dental Check-Up for Children

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 30.00% Coinsurance after deductible

Limit: 2.0 Visit(s) per Year

nan

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Out-of-network 50.00% Coinsurance after deductible

Dentally necessary Orthodontia only.

Exclusions: nan

Routine Dental Services (Adult)

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 30.00% Coinsurance after deductible

nan

Exclusions: nan

Variant attributes

Anthem Dental Family Preventive · Variant 90028WI0420006-00

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

Standard Low Off Exchange Plan

HIOS Product ID

90028WI042

Metal Level

Low

Plan ID (Standard Component ID with Variant)

90028WI0420006-00

Plan Marketing Name

Anthem Dental Family Preventive

Plan Variant Marketing Name

Anthem Dental Family Preventive

Issuer & service area

Issuer-provided metadata for this variant.

Issuer ID

90028

Issuer Marketplace Marketing Name

Anthem Blue Cross and Blue Shield

Market Coverage

Individual

Multiple In Network Tiers

No

National Network

Yes

Network ID

WIN001

Out of Country Coverage

Yes

Out of Country Coverage Description

Out of Country covered services are reimbursed as out-of-network benefits.

Out of Service Area Coverage

Yes

Out of Service Area Coverage Description

If a member does not use a network dentist, services will be reimbursed at the out-of-network level.

Service Area ID

WIS001

State Code

WI

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Inpatient Copayment Maximum Days

0

Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group

per group not applicable

Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person

per person not applicable

Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out

Not Applicable

Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group

$750 per group

Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person

$375 per person

Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual

$375

Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Group

per group not applicable

Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Person

per person not applicable

Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual

Not Applicable

Enrollment & documents

Issuer-provided metadata for this variant.

Plan Brochure

Open link

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

0

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Dental Only Plan

Yes

EHB Apportionment for Pediatric Dental

1.0

First Tier Utilization

100%

Import Date

2024-08-15 01:01:23

Guaranteed Rate

Guaranteed Rate

New/Existing Plan

Existing

Medical EHB Deductible, Combined In/Out of Network, Family Per Group

per group not applicable

Medical EHB Deductible, Combined In/Out of Network, Family Per Person

$50 per person

Medical EHB Deductible, Combined In/Out of Network, Individual

$50

Medical EHB Deductible, In Network (Tier 1), Family Per Group

per group not applicable

Medical EHB Deductible, In Network (Tier 1), Family Per Person

per person not applicable

Medical EHB Deductible, In Network (Tier 1), Individual

Not Applicable

Medical EHB Deductible, Out of Network, Family Per Group

per group not applicable

Medical EHB Deductible, Out of Network, Family Per Person

per person not applicable

Medical EHB Deductible, Out of Network, Individual

Not Applicable

Plan Effective Date

2025-01-01

Plan Expiration Date

2025-12-31

Plan Type

PPO

QHP/Non QHP

Both

Source Name

HIOS

Plan ID

90028WI0420006

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in Wisconsin?

Anthem Dental Family Preventive (90028WI0420006) is a Low PPO from Blue Cross Blue Shield of Wisconsin (PPO and out of network POS) in Wisconsin for the 2025 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does Anthem Dental Family Preventive support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is Anthem Dental Family Preventive HSA-eligible and does it include dental or vision coverage?

HSA eligibility is not published; check the Summary of Benefits or ask the issuer.

Dental add-ons: Adult, Child.

Vision coverage is not listed for this plan.

Does Anthem Dental Family Preventive support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Is there out-of-country coverage for Anthem Dental Family Preventive?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: Out of Country covered services are reimbursed as out-of-network benefits.

Does Anthem Dental Family Preventive cover care outside the service area?

Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: If a member does not use a network dentist, services will be reimbursed at the out-of-network level.

Disclaimer: Based on the Tue, 10 Mar 2026 06:40 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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