Anthem Bronze Pathway X Guided Access HMO 9100/0% Standard - 49046GA0410178 Health Insurance Plan

Anthem Blue Cross and Blue Shield health insurance plan with the Plan ID 49046GA0410178. The plan is called Anthem Bronze Pathway X Guided Access HMO 9100/0% Standard.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 59.86% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 40.14% 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 59.86% (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 40.14% 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 49046GA0410178
Health Insurance Plan Year 2023
State Georgia
Health Insurance Issuer Anthem Blue Cross and Blue Shield
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 49046GA0410178-00
Provider Network(s) ['GAN007']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Georgia 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
Available Variants of the Health Plan

Standard Off Exchange Plan - 49046GA0410178-00

Standard On Exchange Plan - 49046GA0410178-01

Open to Indians below 300% FPL - 49046GA0410178-02

Open to Indians above 300% FPL - 49046GA0410178-03

Last Plan Update Date Fri, 18 Nov 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Anthem Bronze Pathway X Guided Access HMO 9100/0% Standard Health Insurance Plan, 49046GA0410178-00

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

Cost share is driven by provider/setting.

YES

No Charge after deductible

100.00%
Acupuncture
NO
Allergy Testing

Cost share is driven by provider/setting.

YES

No Charge after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

No Charge after deductible

100.00%
Bone Marrow Transplant

Limit: 10000.0 Dollars per Procedure

In-Network Transplant Transportation and Lodging $10,000 Maximum benefit limit per Transplant Unrelated Donor Search $30,000 Maximum benefit limit per Transplant.

YES

No Charge after deductible

100.00%
Chemotherapy

Cost share is driven by provider/setting.

YES

No Charge after deductible

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

Visit limit is combined both across outpatient and other professional visits. Cost share is driven by provider/setting. 20 Visits per year.

YES

No Charge after deductible

100.00%
Clinical Trials
YES

No Charge after deductible

100.00%
Cosmetic Surgery

Reconstructive surgery is covered. Reconstructive surgery is performed to correct deformities caused by congenital or developmental abnormalities, illness, injury, or previous therapeutic process, for the purpose of improving bodily function or symptomatology or to create a normal appearance, including surgery performed to restore symmetry following mastectomy. Reconstructive services required due to prior therapeutic process are covered only if the original procedure would have been a covered service under the plan.

YES

No Charge after deductible

100.00%
Delivery and All Inpatient Services for Maternity Care

Hospital stay is 48 hours for vaginal delivery and 96 hours for c-section

YES

No Charge after deductible

100.00%
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Year

YES

No Charge after deductible

100.00%
Diabetes Care Management
YES

No Charge after deductible

100.00%
Diabetes Education

Cost share is driven by provider/setting.

YES

No Charge after deductible

100.00%
Dialysis

Cost share is driven by provider/setting.

YES

No Charge after deductible

100.00%
Durable Medical Equipment

Hearing Aids covered In-Network only for under age 18 only. Limit 1 per ear every 48 months with a $3000 cap per ear every 48 months.

YES

No Charge after deductible

100.00%
Emergency Room Services

Copayment (if applicable) is waived if admitted.

YES

No Charge after deductible

No Charge after deductible
Emergency Transportation/Ambulance

NON-emergency ambulance/transportation out of network is NOT covered, unless prior authorization is obtained. If authorized out of network, limited to $50,000 per occurrence.

YES

No Charge after deductible

No Charge after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs

30 day retail supply

YES

No Charge after deductible

100.00%
Habilitation Services

Limit: 20.0 Visit(s) per Year

20 visits for Rehabilitation Speech Therapy and 20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy. Speech Therapy, Occupational Therapy and Physical Therapy limits will not apply for children ages 0-20 with Autism (ASD) diagnosis. Plans will include Applied Behavioral Analysis (ABA) services with no visit max for In-Network services for children ages 0-20 with ASD diagnosis. ABA services are subject to medical necessity and will require an authorization.

YES

No Charge after deductible

100.00%
Hearing Aids

Benefit is covered for members through age 18. Limited to $3000 per ear every 48 months.

YES

No Charge after deductible

100.00%
Heart Transplant

Limit: 10000.0 Dollars per Procedure

In-Network Transplant Transportation and Lodging $10,000 Maximum benefit limit per Transplant Unrelated Donor Search $30,000 Maximum benefit limit per Transplant.

YES

No Charge after deductible

100.00%
Home Health Care Services

Limit: 120.0 Visit(s) per Year

Limit also applies to Physical, Occupational or Speech Therapy when performed as part of Home Health Care Services.

YES

No Charge after deductible

100.00%
Hospice Services
YES

No Charge after deductible

100.00%
Imaging (CT/PET Scans, MRIs)

Cost share is driven by provider/setting.

YES

No Charge after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy

Cost share is driven by provider/setting.

YES

No Charge after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

Combined 60 days per year for Inpatient Rehabilitation and Skilled Nursing Facility services.

YES

No Charge after deductible

100.00%
Inpatient Physician and Surgical Services
YES

No Charge after deductible

100.00%
Laboratory Outpatient and Professional Services

Cost share is driven by provider/setting.

YES

No Charge after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

No Charge after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

No Charge after deductible

100.00%
Mental/Behavioral Health Outpatient Services

Cost share is driven by provider/setting.

YES

No Charge after deductible

100.00%
Non-Preferred Brand Drugs

30 day retail supply

YES

No Charge after deductible

100.00%
Nutritional Counseling

Limit: 4.0 Visit(s) per Year

Covered only for treatment of morbid obesity. Excluded Nutritional supplements; services, supplies and/or nutritional sustenance products. Limited to 4 visits per year.

YES

No Charge after deductible

100.00%
Off Label Prescription Drugs
YES

0.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Medically Necessary Orthodontia only

YES

No Charge after deductible

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)

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 mobile app, website, or Anthem-enabled devices

YES

No Charge after deductible

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

No Charge after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Year

20 visits for Rehabilitation Speech Therapy and 20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy. Speech Therapy, Occupational Therapy and Physical Therapy limits will not apply for children ages 0-20 with Autism (ASD) diagnosis.

YES

No Charge after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

No Charge after deductible

100.00%
Preferred Brand Drugs

30 day retail supply

YES

No Charge after deductible

100.00%
Prenatal and Postnatal Care
YES

No Charge after deductible

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness

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 mobile app, website, or Anthem-enabled devices

YES

No Charge after deductible

100.00%
Private-Duty Nursing
NO
Prosthetic Devices

Wigs are limited to 1 (one) per year as needed after cancer treatment.?

YES

No Charge after deductible

100.00%
Radiation

Cost share is driven by provider/setting.

YES

No Charge after deductible

100.00%
Reconstructive Surgery

Reconstructive surgery is covered. Reconstructive surgery is performed to correct deformities caused by congenital or developmental abnormalities, illness, injury, or previous therapeutic process, for the purpose of improving bodily function or symptomatology or to create a normal appearance, including surgery performed to restore symmetry following mastectomy. Reconstructive services required due to prior therapeutic process are covered only if the original procedure would have been a covered service under the plan.

YES

No Charge after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Year

20 visits combined for Rehabilitation Physical Therapy and Rehabilitation Occupational Therapy. Speech Therapy, Occupational Therapy and Physical Therapy limits will not apply for children ages 0-20 with Autism (ASD) diagnosis.

YES

No Charge after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

20 visits for Rehabilitation Speech Therapy.? Speech Therapy?limits will not apply for children ages 0-20 ?with Autism (ASD) diagnosis.

YES

No Charge after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Year

Combined days for Inpatient Rehabilitation and Skilled Nursing Facility services. 60 Days per year.

YES

No Charge after deductible

100.00%
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 mobile app, website, or Anthem-enabled devices

YES

No Charge after deductible

100.00%
Specialty Drugs

30 day supply

YES

No Charge after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

No Charge after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Cost share is driven by provider/setting.

YES

No Charge after deductible

100.00%
Transplant

Limit: 10000.0 Dollars per Procedure

In-Network Transplant Transportation and Lodging $10,000 Maximum benefit limit per Transplant Unrelated Donor Search $30,000 Maximum benefit limit per Transplant.

YES

No Charge after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

No Charge after deductible

100.00%
Urgent Care Centers or Facilities

Additional Cost Share determined based on service received

YES

No Charge after deductible

No Charge after deductible
Weight Loss Programs

Limit: 4.0 Visit(s) per Year

Covered only for treatment of morbid obesity. Excluded Nutritional supplements; services, supplies and/or nutritional sustenance products. Limited to 4 visits per year.

YES

No Charge after deductible

100.00%
Well Baby Visits and Care

Care provided for birth through age 5.

YES

No Charge

100.00%
Well Child Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging

Cost share is driven by provider/setting.

YES

No Charge after deductible

100.00%

Anthem Bronze Pathway Guided Access HMO 9100/0% Standard Health Insurance Plan Variant 49046GA0410178-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.5986
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
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 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
First Tier Utilization 100%
Formulary ID GAF006
Formulary URL URL
HIOS Product ID 49046GA041
Import Date 11/18/2022 1:01
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? Yes
Issuer Actuarial Value 59.86%
Issuer ID 49046
Issuer Marketplace Marketing Name Blue Cross Blue Shield Healthcare Plan of Georgia, Inc
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Bronze
Multiple In Network Tiers No
National Network No
Network ID GAN007
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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 49046GA0410178-00
Plan Marketing Name Anthem Bronze Pathway X Guided Access HMO 9100/0% Standard
Plan Type HMO
Plan Variant Marketing Name Anthem Bronze Pathway Guided Access HMO 9100/0% Standard
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $9,100
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $5,400
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
Service Area ID GAS020
Source Name HIOS
Specialist Requiring a Referral You do not need a Referral or approval from Your PCP to see an Obstetrician/Gynecologist (OB/GYN), Dermatologist, or eye care professionals including Optometrists and Ophthalmologists.
Plan ID 49046GA0410178
State Code GA
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 $18200 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $9100 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $9,100
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 $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,100
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 Anthem Bronze Pathway X Guided Access HMO 9100/0% Standard Health Insurance Plan, 49046GA0410178

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

Frequently Asked Questions(FAQ) about Anthem Bronze Pathway X Guided Access HMO 9100/0% Standard, 49046GA0410178 Health Insurance Plan, 49046GA0410178

  • Does Anthem Bronze Pathway X Guided Access HMO 9100/0% Standard Health Insurance Plan, 49046GA0410178 support Mail Ordering?

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

  • Does (49046GA0410178) Health Insurance Plan, Variant (49046GA0410178-00) 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 (49046GA0410178) Health Insurance Plan, Variant (49046GA0410178-00) 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 (49046GA0410178) Health Insurance Plan, Variant (49046GA0410178-00) 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 (49046GA0410178) Health Insurance Plan, Variant (49046GA0410178-00) 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 Pathway Guided Access HMO 9100/0% Standard Health Insurance Plan, Variant (49046GA0410178-00) offer Disease Management Programs for Asthma?

    Yes, the Anthem Bronze Pathway Guided Access HMO 9100/0% Standard Health Insurance Plan Variant 49046GA0410178-00 offers Disease Management Program for Asthma.

    Does Anthem Bronze Pathway Guided Access HMO 9100/0% Standard Health Insurance Plan, Variant (49046GA0410178-00) offer Disease Management Programs for Heart disease?

    Yes, the Anthem Bronze Pathway Guided Access HMO 9100/0% Standard Health Insurance Plan Variant 49046GA0410178-00 offers Disease Management Program for Heart disease.

    Does Anthem Bronze Pathway Guided Access HMO 9100/0% Standard Health Insurance Plan, Variant (49046GA0410178-00) offer Disease Management Programs for Depression?

    Yes, the Anthem Bronze Pathway Guided Access HMO 9100/0% Standard Health Insurance Plan Variant 49046GA0410178-00 offers Disease Management Program for Depression.

    Does Anthem Bronze Pathway Guided Access HMO 9100/0% Standard Health Insurance Plan, Variant (49046GA0410178-00) offer Disease Management Programs for Diabetes?

    Yes, the Anthem Bronze Pathway Guided Access HMO 9100/0% Standard Health Insurance Plan Variant 49046GA0410178-00 offers Disease Management Program for Diabetes.

    Does Anthem Bronze Pathway Guided Access HMO 9100/0% Standard Health Insurance Plan, Variant (49046GA0410178-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Anthem Bronze Pathway Guided Access HMO 9100/0% Standard Health Insurance Plan Variant 49046GA0410178-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Anthem Bronze Pathway Guided Access HMO 9100/0% Standard Health Insurance Plan, Variant (49046GA0410178-00) offer Disease Management Programs for Low back pain?

    Yes, the Anthem Bronze Pathway Guided Access HMO 9100/0% Standard Health Insurance Plan Variant 49046GA0410178-00 offers Disease Management Program for Low back pain.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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