Anthem Silver Pathway X 3000 for HSA - 32753MO0950007 Health Insurance Plan

Healthy Alliance Life Co(Anthem BCBS) health insurance plan with the Plan ID 32753MO0950007. The plan is called Anthem Silver Pathway X 3000 for HSA.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.06% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.94% 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 71.54% (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 28.46% 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 32753MO0950007
Health Insurance Plan Year 2023
State Missouri
Health Insurance Issuer Healthy Alliance Life Co(Anthem BCBS)
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 32753MO0950007-00
Provider Network(s) ['MON001']
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 Missouri 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 - 32753MO0950007-00

Standard On Exchange Plan - 32753MO0950007-01

Open to Indians below 300% FPL - 32753MO0950007-02

Open to Indians above 300% FPL - 32753MO0950007-03

73% AV Silver Plan - 32753MO0950007-04

87% AV Silver Plan - 32753MO0950007-05

94% AV Silver Plan - 32753MO0950007-06

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

Benefits of Anthem Silver Pathway X 3000 for HSA Health Insurance Plan, 32753MO0950007-00

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

Limit: 3000.0 Dollars per Episode

YES

20.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

20.00% Coinsurance after deductible

100.00%
Applied Behavior Analysis Based Therapies

Limited to members through 18 years of age.

YES

20.00% Coinsurance after deductible

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

50.00% Coinsurance after deductible

100.00%
Bone Marrow Testing
YES

20.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

20.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 26.0 Visit(s) per Year

Chiropractic Manipulation Therapy visits beyond the 26 visit limit require Prior Authorization from Anthem in order to be covered.

YES

20.00% Coinsurance after deductible

100.00%
Clinical Trials
YES

$500.00 Copay after deductible, 40.00% Coinsurance after deductible

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

$500.00 Copay after deductible, 40.00% Coinsurance after deductible

100.00%
Dental Anesthesia

Benefits are provided only for the administration of general anesthesia and for both facility and professional charges occurring in connection with dental services, regardless of age, when prior authorization for an inpatient dental care procedure is approved by us. In addition, and as required by law, benefits for the administration of general anesthesia, including facility and professional charges, are provided for the following Members: ? A Member through the age of four; ? A Member who is severely disabled; and ? A Member who has a medical or behavioral condition that requires hospitalization or general anesthesia when dental services are provided.

YES

20.00% 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

20.00% Coinsurance after deductible

100.00%
Dialysis
YES

20.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

20.00% Coinsurance after deductible

100.00%
Emergency Room Services

Emergency Room copay is waived if directly admitted to the hospital.

YES

$500.00 Copay after deductible, 20.00% Coinsurance after deductible

$500.00 Copay after deductible, 20.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Non-emergency ambulance/transportation out of network is NOT covered, unless prior authorization is obtained from Anthem. Authorized out of network is limited to $50,000 per occurrence.

YES

20.00% Coinsurance after deductible

20.00% 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

Cost share shown is for a 30 day supply.

YES

Tier 1: 20.00% Coinsurance after deductible

Tier 2: 30.00% Coinsurance after deductible

100.00%
Habilitation Services

Limit: 40.0 Visit(s) per Year

Rehabilitative Physical Therapy and Occupational Therapy is limited to 20 visits per year.? For Covered Services you receive in the office from a Physical Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?For Covered Services you receive in the office from an Occupational Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?All other services are subject to deductible and coinsurance.? These limitations do not apply to any Autism Spectrum Disorder diagnosis or to Mental Health and Substance Abuse conditions.? Cost share is driven by provider and setting.

YES

20.00% Coinsurance after deductible

100.00%
Hearing Aids

One hearing aid per ear every 36 months. Limit does not apply to newborn.

YES

20.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 100.0 Visit(s) per Year

Benefit includes coverage for Private Duty Nursing in the home and Private Duty Nursing is limited to 82 visits per calendar year.

YES

20.00% Coinsurance after deductible

100.00%
Hospice Services
YES

20.00% 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

20.00% Coinsurance after deductible

100.00%
Inherited Metabolic Disorder - PKU
YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 50.00% Coinsurance after deductible

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

$500.00 Copay per Stay after deductible, 40.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

20.00% 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

$500.00 Copay per Stay after deductible, 40.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

Limitation of Two office visits per member per Year with a Non-Network licensed provider.

YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Newborn Hearing Screening
YES

$500.00 Copay after deductible, 40.00% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs

Cost share shown is for a 30 day supply.

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 50.00% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

20.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
YES

50.00% Coinsurance 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 Sydney application.

YES

20.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 40.0 Visit(s) per Year

Rehabilitative Physical Therapy and Occupational Therapy is limited to 20 visits per year.? For Covered Services you receive in the office from a Physical Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?For Covered Services you receive in the office from an Occupational Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?All other services are subject to deductible and coinsurance.? These limitations do not apply to any Autism Spectrum Disorder diagnosis or to Mental Health and Substance Abuse conditions.? Cost share is driven by provider and setting.

YES

20.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Cost share shown is for a 30 day supply.

YES

Tier 1: 20.00% Coinsurance after deductible

Tier 2: 30.00% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care
YES

20.00% 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. Immunizations prior to 6th birthday covered in full.

YES

No Charge

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 Sydney application.

YES

20.00% Coinsurance after deductible

100.00%
Private-Duty Nursing

Limit: 82.0 Visit(s) per Year

Benefit includes coverage for Private Duty Nursing in the home and Private Duty Nursing is limited to 82 visits per calendar year.

YES

20.00% Coinsurance after deductible

100.00%
Prosthetic Devices

Benefits include the purchase, fitting, adjustments, repairs and replacements.

YES

20.00% Coinsurance after deductible

100.00%
Radiation
YES

20.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance.

YES

$500.00 Copay after deductible, 40.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Year

Rehabilitative Physical Therapy and Occupational Therapy is limited to 20 visits per year.? For Covered Services you receive in the office from a Physical Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?For Covered Services you receive in the office from an Occupational Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?All other services are subject to deductible and coinsurance.? These limitations do not apply to any Autism Spectrum Disorder diagnosis or to Mental Health and Substance Abuse conditions.? Cost share is driven by provider and setting.

YES

20.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy
YES

20.00% 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

Coverage is available if Medically Necessary Services

YES

20.00% Coinsurance after deductible

100.00%
Skilled Nursing Facility

Limit: 150.0 Days per Year

Limited to 150 combined days per calendar year for Physical Medicine, Rehabilitation and Skilled Nursing Facility services.

YES

20.00% Coinsurance 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 Sydney application.

YES

20.00% Coinsurance after deductible

100.00%
Specialty Drugs

Cost share shown is for a 30 day supply.

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

$500.00 Copay per Stay after deductible, 40.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Limitation of Two office visits per member per Year with a Non-Network licensed provider.

YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Transplant

Includes coverage for travel/lodging as approved by the plan ($10,000 per transplant). Donor search charges are limited to 10 best matched donors identified by an authorized registry.

YES

$500.00 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, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures).

YES

20.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

20.00% Coinsurance after deductible

100.00%

Anthem Silver Pathway 3000 for HSA Health Insurance Plan Variant 32753MO0950007-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.715396432
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 Silver 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 38%
Formulary ID MOF002
Formulary URL URL
HIOS Product ID 32753MO095
Import Date 8/18/2022 1:00
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 71.06%
Issuer ID 32753
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 MON001
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 Standard Bluecard PPO Network
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 32753MO0950007-00
Plan Marketing Name Anthem Silver Pathway X 3000 for HSA
Plan Type EPO
Plan Variant Marketing Name Anthem Silver Pathway 3000 for HSA
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,300
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $3,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $500
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $3,000
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 62%
Service Area ID MOS001
Source Name HIOS
Plan ID 32753MO0950007
State Code MO
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 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $6000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $3000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $3,000
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $6000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $3000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $3,000
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 $12900 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $6450 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $6,450
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $12900 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $6450 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $6,450
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 Silver Pathway X 3000 for HSA Health Insurance Plan, 32753MO0950007

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

Frequently Asked Questions(FAQ) about Anthem Silver Pathway X 3000 for HSA, 32753MO0950007 Health Insurance Plan, 32753MO0950007

  • Does Anthem Silver Pathway X 3000 for HSA Health Insurance Plan, 32753MO0950007 support Mail Ordering?

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

  • Does (32753MO0950007) Health Insurance Plan, Variant (32753MO0950007-00) 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 (32753MO0950007) Health Insurance Plan, Variant (32753MO0950007-00) 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 (32753MO0950007) Health Insurance Plan, Variant (32753MO0950007-00) 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: Standard Bluecard PPO Network

    Does (32753MO0950007) Health Insurance Plan, Variant (32753MO0950007-00) 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 Silver Pathway 3000 for HSA Health Insurance Plan, Variant (32753MO0950007-00) offer Disease Management Programs for Asthma?

    Yes, the Anthem Silver Pathway 3000 for HSA Health Insurance Plan Variant 32753MO0950007-00 offers Disease Management Program for Asthma.

    Does Anthem Silver Pathway 3000 for HSA Health Insurance Plan, Variant (32753MO0950007-00) offer Disease Management Programs for Heart disease?

    Yes, the Anthem Silver Pathway 3000 for HSA Health Insurance Plan Variant 32753MO0950007-00 offers Disease Management Program for Heart disease.

    Does Anthem Silver Pathway 3000 for HSA Health Insurance Plan, Variant (32753MO0950007-00) offer Disease Management Programs for Depression?

    Yes, the Anthem Silver Pathway 3000 for HSA Health Insurance Plan Variant 32753MO0950007-00 offers Disease Management Program for Depression.

    Does Anthem Silver Pathway 3000 for HSA Health Insurance Plan, Variant (32753MO0950007-00) offer Disease Management Programs for Diabetes?

    Yes, the Anthem Silver Pathway 3000 for HSA Health Insurance Plan Variant 32753MO0950007-00 offers Disease Management Program for Diabetes.

    Does Anthem Silver Pathway 3000 for HSA Health Insurance Plan, Variant (32753MO0950007-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Anthem Silver Pathway 3000 for HSA Health Insurance Plan Variant 32753MO0950007-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Anthem Silver Pathway 3000 for HSA Health Insurance Plan, Variant (32753MO0950007-00) offer Disease Management Programs for Low back pain?

    Yes, the Anthem Silver Pathway 3000 for HSA Health Insurance Plan Variant 32753MO0950007-00 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