Anthem Silver Preferred/Broad 4000 (3 Free PCP Visits + $0 Select Drugs + Incentives) - 79475WI0530017 Health Insurance Plan
Compcare Health Serv Ins Co(Anthem BCBS) health insurance plan with the Plan ID 79475WI0530017. The plan is called Anthem Silver Preferred/Broad 4000 (3 Free PCP Visits + $0 Select Drugs + Incentives).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 100.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% 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 100.00% (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 0.00% 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 | 79475WI0530017 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Compcare Health Serv Ins Co(Anthem BCBS) | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 79475WI0530017-02 | ||||||||||||||||||
| Provider Network(s) | PARTICIPATING | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 Oct 2025 05:27 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 79475WI0530017-00 Standard On Exchange Plan - 79475WI0530017-01 Open to Indians below 300% FPL - 79475WI0530017-02 Open to Indians above 300% FPL - 79475WI0530017-03 73% AV Silver Plan - 79475WI0530017-04 |
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| Last Plan Update Date | Tue, 14 Jan 2025 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 Oct 2025 05:27 GMT |
Benefits of Anthem Silver Preferred/Broad 4000 (3 Free PCP Visits + $0 Select Drugs + Incentives) Health Insurance Plan, 79475WI0530017-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan Limited to therapeutic (only in case of rape, incest or health of mother) |
NO | ||
| Accidental Dental
Limit: 3000.0 Dollars per Episode Exclusions: nan Limited to $900 per tooth |
YES | $0.00 |
0.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan nan |
NO | ||
| Bariatric Surgery
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
YES | 0.00% |
0.00% |
| Chemotherapy
Exclusions: nan nan |
YES | 0.00% |
0.00% |
| Chiropractic Care
Exclusions: nan Member is responsible for the Primary Care Physician cost share amount when service is performed by a Primary Care Physician or Chiropractor. |
YES | $0.00 |
0.00% |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan Excludes services related to surrogacy if member is not the surrogate. |
YES | $0.00, 0.00% |
0.00% |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year Exclusions: nan nan |
YES | $0.00 |
0.00% |
| Diabetes Education
Exclusions: nan nan |
YES | $0.00 |
0.00% |
| Dialysis
Exclusions: nan nan |
YES | 0.00% |
0.00% |
| Durable Medical Equipment
Limit: 1.0 Item(s) per 3 Years Exclusions: nan Limited to a single purchase of a type of Durable Medical Equipment/Prosthetic (including repair and replacement) every 3 years. |
YES | 0.00% |
0.00% |
| Emergency Room Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
Exclusions: nan Non-emergency ambulance/transportation out of network is not covered unless authorized. Authorized out of network is limited to $50,000 per occurrence. |
YES | 0.00% |
0.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: nan nan |
YES | $0.00 |
$0.00 |
| Gender Affirming Care
Exclusions: nan nan |
NO | ||
| Generic Drugs
Exclusions: nan 30 day supply retail |
YES | Tier 1: $0.00 Tier 2: $0.00 |
0.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Year Exclusions: nan 20 visit limit for each Physical Therapy, Occupational Therapy and Speech Therapy |
YES | 0.00% |
0.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Exclusions: nan 1 hearing aid per ear every 3 years |
YES | 0.00% |
0.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Exclusions: nan nan |
YES | 0.00% |
0.00% |
| Hospice Services
Exclusions: nan nan |
YES | 0.00% |
0.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | $0.00, 0.00% |
0.00% |
| Infertility Treatment
Exclusions: nan nan |
NO | ||
| Infusion Therapy
Exclusions: nan nan |
YES | 0.00% |
0.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis) Limited to a maximum of 60 days per Member, per Calendar Year. |
YES | $0.00, 0.00% |
0.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | 0.00% |
0.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | 0.00% |
0.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
YES | 0.00% |
0.00% |
| Mental/Behavioral Health Inpatient Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
0.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan 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 |
0.00% |
| Non-Preferred Brand Drugs
Exclusions: nan 30 day supply retail |
YES | Tier 1: 0.00% Tier 2: 0.00% |
0.00% |
| Nutritional Counseling
Exclusions: nan nan |
NO | ||
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
YES | 0.00% |
0.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan Copay is for Primary Care office visit and Specialist Office visits only, other services provided during the visit are subject to deductible and coinsurance. 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 | $0.00 |
0.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | 0.00% |
0.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Exclusions: nan 20 visit limit for each Physical Therapy, Occupational Therapy and Speech Therapy |
YES | 0.00% |
0.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | 0.00% |
0.00% |
| Preferred Brand Drugs
Exclusions: nan 30 day supply retail |
YES | Tier 1: $0.00 Tier 2: $0.00 |
0.00% |
| Prenatal and Postnatal Care
Exclusions: nan nan |
YES | 0.00% |
0.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan 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. Covered Services also include lead poisoning screening for Dependents under age six (6), as required by state law. |
YES | $0.00 |
0.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan Copay is for Primary Care office visit and Specialist Office visits only, other services provided during the visit are subject to deductible and coinsurance. 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 | $0.00 |
0.00% |
| Private-Duty Nursing
Exclusions: nan nan |
NO | ||
| Prosthetic Devices
Limit: 1.0 Item(s) per 3 Years Exclusions: nan Limit is applicable to a single purchase of a type of prosthetic device. Limit does not apply to prosthetics required by the Womens Health and Cancer Rights Act of 1998. |
YES | 0.00% |
0.00% |
| Radiation
Exclusions: nan nan |
YES | 0.00% |
0.00% |
| Reconstructive Surgery
Exclusions: nan nan |
YES | $0.00, 0.00% |
0.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year Exclusions: nan 20 visits each Physical Therapy/Occupational Therapy per year. Limit is combined across professional visits and outpatient facilities. |
YES | 0.00% |
0.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Exclusions: nan Limit is combined across professional visits and outpatient facilities. |
YES | 0.00% |
0.00% |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year Exclusions: nan nan |
YES | $0.00 |
$0.00 |
| Routine Foot Care
Exclusions: nan nan |
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Admission Exclusions: nan nan |
YES | 0.00% |
0.00% |
| Specialist Visit
Exclusions: nan Copay is for Primary Care office visit and Specialist Office visits only, other services provided during the visit are subject to deductible and coinsurance. 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 | $0.00 |
0.00% |
| Specialty Drugs
Exclusions: nan 30 day supply retail |
YES | Tier 1: 0.00% Tier 2: 0.00% |
0.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
0.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan 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 |
0.00% |
| Transplant
Exclusions: nan nan |
YES | $0.00, 0.00% |
0.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. Covered Services do not include fixed or removable appliances that involve movement or repositioning of the teeth (braces), repair of teeth (fillings), or prosthetics (crowns, bridges, dentures) |
YES | 0.00% |
0.00% |
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $0.00 |
$0.00 |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan Benefits are covered under preventive care. |
YES | $0.00 |
0.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan nan |
YES | 0.00% |
0.00% |
Anthem Silver Preferred/Broad (+ Incentives) AI Health Insurance Plan Variant 79475WI0530017-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1.0 |
| 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 | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 32% |
| Formulary ID | WIF530 |
| Formulary URL | URL |
| HIOS Product ID | 79475WI053 |
| Import Date | 2025-01-14 00:02:24 |
| 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 | 100.00% |
| Issuer ID | 79475 |
| 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 | Silver |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | WIN003 |
| 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) | 79475WI0530017-02 |
| Plan Marketing Name | Anthem Silver Preferred/Broad 4000 (3 Free PCP Visits + $0 Select Drugs + Incentives) |
| Plan Type | POS |
| Plan Variant Marketing Name | Anthem Silver Preferred/Broad (+ Incentives) AI |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| 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 | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 68% |
| Service Area ID | WIS010 |
| Source Name | HIOS |
| Plan ID | 79475WI0530017 |
| State Code | WI |
| 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 | $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, In Network (Tier 2), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Anthem Silver Preferred/Broad 4000 (3 Free PCP Visits + $0 Select Drugs + Incentives) Health Insurance Plan, 79475WI0530017
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Anthem Silver Preferred/Broad 4000 (3 Free PCP Visits + $0 Select Drugs + Incentives), 79475WI0530017 Health Insurance Plan, 79475WI0530017
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Does Anthem Silver Preferred/Broad 4000 (3 Free PCP Visits + $0 Select Drugs + Incentives) Health Insurance Plan, 79475WI0530017 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (79475WI0530017) Health Insurance Plan, Variant (79475WI0530017-02) offer Disease Management Programs?
Does (79475WI0530017) Health Insurance Plan, Variant (79475WI0530017-02) have Out Of Country Coverage?
Does (79475WI0530017) Health Insurance Plan, Variant (79475WI0530017-02) have Out of Service Area Coverage?
Does (79475WI0530017) Health Insurance Plan, Variant (79475WI0530017-02) offer Disease Management Programs?
Does Anthem Silver Preferred/Broad (+ Incentives) AI Health Insurance Plan, Variant (79475WI0530017-02) offer Disease Management Programs for Asthma?
Does Anthem Silver Preferred/Broad (+ Incentives) AI Health Insurance Plan, Variant (79475WI0530017-02) offer Disease Management Programs for Heart disease?
Does Anthem Silver Preferred/Broad (+ Incentives) AI Health Insurance Plan, Variant (79475WI0530017-02) offer Disease Management Programs for Depression?
Does Anthem Silver Preferred/Broad (+ Incentives) AI Health Insurance Plan, Variant (79475WI0530017-02) offer Disease Management Programs for Diabetes?
Does Anthem Silver Preferred/Broad (+ Incentives) AI Health Insurance Plan, Variant (79475WI0530017-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Anthem Silver Preferred/Broad (+ Incentives) AI Health Insurance Plan, Variant (79475WI0530017-02) offer Disease Management Programs for Low back pain?
Disclaimer: This is based on the import(Date: Tue, 07 Oct 2025 05:27 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