Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) - 79475WI0340110 Health Insurance Plan

Compcare Health Serv Ins Co(Anthem BCBS) health insurance plan with the Plan ID 79475WI0340110. The plan is called Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives).

Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.17% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.83% 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 79.02% (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 20.98% 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 79475WI0340110
Health Insurance Plan Year 2023
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 79475WI0340110-00
Provider Network(s) ['WIN001']
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 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
Available Variants of the Health Plan

Standard Off Exchange Plan - 79475WI0340110-00

Standard On Exchange Plan - 79475WI0340110-01

Open to Indians below 300% FPL - 79475WI0340110-02

Open to Indians above 300% FPL - 79475WI0340110-03

Last Plan Update Date Sat, 03 Dec 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 79475WI0340110-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited

Limited to therapeutic (only in case of rape, incest or health of mother)

NO
Accidental Dental

Limit: 3000.0 Dollars per Episode

Limited to $900 per tooth

YES

30.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

30.00% Coinsurance after deductible

100.00%
Chiropractic Care

Member is responsible for the Primary Care Physician cost share amount when service is performed by a Primary Care Physician or Chiropractor.

YES

$30.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Excludes services related to surrogacy if member is not the surrogate.

YES

$750.00 Copay after deductible, 40.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Year

YES

No Charge after deductible

100.00%
Diabetes Education
YES

30.00% Coinsurance after deductible

100.00%
Dialysis
YES

30.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Limit: 1.0 Item(s) per 3 Years

Limited to a single purchase of a type of Durable Medical Equipment/Prosthetic (including repair and replacement) every 3 years.

YES

30.00% Coinsurance after deductible

100.00%
Emergency Room Services

If applicable, copay waived if admitted.

YES

$500.00 Copay after deductible, 30.00% Coinsurance after deductible

$500.00 Copay after deductible, 30.00% 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 occurrence.

YES

30.00% Coinsurance after deductible

30.00% Coinsurance 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 supply retail

YES

Tier 1: $10.00

Tier 2: $25.00

100.00%
Habilitation Services

Limit: 60.0 Visit(s) per Year

20 visit limit for each Physical Therapy, Occupational Therapy and Speech Therapy

YES

30.00% Coinsurance after deductible

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

1 hearing aid per ear every 3 years

YES

30.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

YES

30.00% Coinsurance after deductible

100.00%
Hospice Services
YES

30.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

$500.00 Copay after deductible, 40.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

30.00% Coinsurance after deductible

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

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

$750.00 Copay per Stay after deductible, 40.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

30.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

30.00% Coinsurance after deductible

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

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

$750.00 Copay per Stay after deductible, 40.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

30.00% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs

30 day supply retail

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 55.00% Coinsurance after deductible

100.00%
Nutritional Counseling
NO
Orthodontia - Adult
NO
Orthodontia - Child
YES

50.00% Coinsurance after deductible

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

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

$30.00

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

30.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Year

20 visit limit for each Physical Therapy, Occupational Therapy and Speech Therapy

YES

30.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

30.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

30 day supply retail

YES

Tier 1: $50.00

Tier 2: $65.00

100.00%
Prenatal and Postnatal Care
YES

30.00% Coinsurance after deductible

100.00%
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. Covered Services also include lead poisoning screening for Dependents under age six (6), as required by state law.

YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

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

$30.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices

Limit: 1.0 Item(s) per 3 Years

Limit is applicable to a single purchase of a type of prosthetic device. Limit does not apply to prosthetics required by the Women?s Health and Cancer Rights Act of 1998.

YES

30.00% Coinsurance after deductible

100.00%
Radiation
YES

30.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

$750.00 Copay after deductible, 40.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Year

20 visits each Physical Therapy/Occupational Therapy per year. Limit is combined across professional visits and outpatient facilities.

YES

30.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Limit is combined across professional visits and outpatient facilities.

YES

30.00% Coinsurance 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: 30.0 Days per Admission

YES

30.00% Coinsurance after deductible

100.00%
Specialist Visit

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

30.00% Coinsurance after deductible

100.00%
Specialty Drugs

30 day supply retail

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 55.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

$750.00 Copay per Stay after deductible, 40.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

30.00% Coinsurance after deductible

100.00%
Transplant
YES

$750.00 Copay after deductible, 40.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

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

30.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$75.00

$75.00
Weight Loss Programs
NO
Well Baby Visits and Care

Benefits are covered under preventive care.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

30.00% Coinsurance after deductible

100.00%

Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 79475WI0340110-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.790170719
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 Gold 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
First Tier Utilization 34%
Formulary ID WIF008
Formulary URL URL
HIOS Product ID 79475WI034
Import Date 12/3/2022 1:01
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 78.17%
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 Gold
Multiple In Network Tiers Yes
National Network No
Network ID WIN001
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) 79475WI0340110-00
Plan Marketing Name Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives)
Plan Type HMO
Plan Variant Marketing Name Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $4,200
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $1,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,600
SBC Scenario, Having Diabetes, Deductible $400
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $500
SBC Scenario, Treatment of a Simple Fracture, Copayment $10
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,000
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 66%
Service Area ID WIS001
Source Name HIOS
Plan ID 79475WI0340110
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 30.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $2000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $1000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,000
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 30.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $2000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $1000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $1,000
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 $13800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $6900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $6,900
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $13800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $6900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $6,900
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 Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 79475WI0340110

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

Frequently Asked Questions(FAQ) about Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives), 79475WI0340110 Health Insurance Plan, 79475WI0340110

  • Does Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, 79475WI0340110 support Mail Ordering?

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

  • Does (79475WI0340110) Health Insurance Plan, Variant (79475WI0340110-00) 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 (79475WI0340110) Health Insurance Plan, Variant (79475WI0340110-00) 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 (79475WI0340110) Health Insurance Plan, Variant (79475WI0340110-00) 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 (79475WI0340110) Health Insurance Plan, Variant (79475WI0340110-00) 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 Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (79475WI0340110-00) offer Disease Management Programs for Asthma?

    Yes, the Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 79475WI0340110-00 offers Disease Management Program for Asthma.

    Does Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (79475WI0340110-00) offer Disease Management Programs for Heart disease?

    Yes, the Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 79475WI0340110-00 offers Disease Management Program for Heart disease.

    Does Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (79475WI0340110-00) offer Disease Management Programs for Depression?

    Yes, the Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 79475WI0340110-00 offers Disease Management Program for Depression.

    Does Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (79475WI0340110-00) offer Disease Management Programs for Diabetes?

    Yes, the Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 79475WI0340110-00 offers Disease Management Program for Diabetes.

    Does Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (79475WI0340110-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 79475WI0340110-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan, Variant (79475WI0340110-00) offer Disease Management Programs for Low back pain?

    Yes, the Anthem Gold Pathway/Lean 1000 ($0 Virtual PCP + $0 Select Drugs + Incentives) Health Insurance Plan Variant 79475WI0340110-00 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