Wellpoint Essential Silver 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives)

47501TX0040013
Silver
HMO

Wellpoint Essential Silver 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) is a Silver HMO plan by WellPoint.

Locations

Wellpoint Essential Silver 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) is offered in the following counties.

Plan Overview

This is a plan overview for 2025 version of Wellpoint Essential Silver 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) 47501TX0040013.
Insurer: WellPoint
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 47501TX0040013

Cost-Sharing Overview

Wellpoint Essential Silver 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Wellpoint Essential Silver 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Wellpoint Essential Silver 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Wellpoint Essential Silver 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) covers when you are out of the service area or out of the country.

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:
National Network: No

Additional Benefits and Cost-Sharing

Wellpoint Essential Silver 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$40.00 Not ApplicableNot Applicable 100.00% Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services. You have $0 virtual visits and medical chats using our preferred virtual care-only Primary Care Physicians (PCP). These services can be accessed via our Sydney application or member website.
Specialist Visit
Covered
$80.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 Not ApplicableNot Applicable 100.00% Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services. You have $0 virtual visits and medical chats using our preferred virtual care-only Primary Care Physicians (PCP). These services can be accessed via our Sydney application or member website.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$60.00 Not Applicable$60.00 Not Applicable
Home Health Care Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Year Limited to a maximum of 60 visits per Member per Calendar Year
Emergency Room Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible NonNetwork nonemergency ambulance services are subject to the same Cost Share as Network services up to $50,000 per trip.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%25.0 Days per Year Limited to a maximum of 25 days per Member, per Calendar Year
Prenatal and Postnatal Care
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$20.00 Not ApplicableNot Applicable 100.00% Retail Pharmacy is limited to a 30-day supply per Prescription.
Preferred Brand Drugs
Covered
$40.00 Not ApplicableNot Applicable 100.00% Retail Pharmacy is limited to a 30-day supply per Prescription.
Non-Preferred Brand Drugs
Covered
$80.00 Copay after deductible Not ApplicableNot Applicable 100.00% Retail Pharmacy is limited to a 30-day supply per Prescription.
Specialty Drugs
Covered
$350.00 Copay after deductible Not ApplicableNot Applicable 100.00% Specialty Drugs must be purchased from the Pharmacy Benefits Manager?s Specialty Pharmacy and are limited to a 30-day supply.
Outpatient Rehabilitation Services
Covered
$40.00 Not ApplicableNot Applicable 100.00%35.0 Visit(s) per Year Limit is combined for rehabilitative physical therapy and manipulation therapy.
Habilitation Services
Covered
$40.00 Not ApplicableNot Applicable 100.00%35.0 Visit(s) per Year Limit is combined for rehabilitative and habilitative physical therapy, occupational therapy and speech therapy. Services submitted with an Autism diagnosis are unlimited for physical, occupational and speech therapy.
Chiropractic Care
Covered
$40.00 Not ApplicableNot Applicable 100.00%35.0 Visit(s) per Year
Durable Medical Equipment
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00% Continuous glucose monitors and related supplies are covered under DME.
Hearing Aids
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per 3 Years Services to restore loss of or correct an impaired speech or hearing function with hearing aids are covered as any other sickness.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable 0.00%Not Applicable 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNot Applicable 100.00% Eye exams are covered once per benefit period. Limit is combined in network and out of network for the exam.
Eye Glasses for Children
Covered
No Charge Not ApplicableNot Applicable 100.00% Frames and lenses or contat lenses are covered once per benefit period. Limit is comnbined in network and out of network.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$40.00 Not ApplicableNot Applicable 100.00%35.0 Visit(s) per Year Limit is combined for rehabilitative and habilitative physical therapy, occupational therapy and speech therapy. Services submitted with an Autism diagnosis are unlimited for physical, occupational and speech therapy.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$40.00 Not ApplicableNot Applicable 100.00%35.0 Visit(s) per Year Limit is combined for rehabilitative and habilitative physical therapy, occupational therapy and speech therapy. Limit is combined for rehabilitative physical therapy and manipulation therapy. Services submitted with an Autism diagnosis are unlimited for physical, occupational and speech therapy.
Well Baby Visits and Care
Covered
No Charge Not ApplicableNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00% Services submitted with an Autism diagnosis are unlimited for physical, occupational and speech therapy.
X-rays and Diagnostic Imaging
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00% Transportation and lodging are not covered out of network. Donor search charges are limited to 10 best matched donors per transplant, identified by an authorized registry.
Accidental Dental
Covered
$80.00 Not ApplicableNot Applicable 100.00%
Dialysis
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
$80.00 Not ApplicableNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Reconstructive Surgery
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Gender Affirming Care
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following Wellpoint Essential Silver 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Wellpoint Essential Silver 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives) including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Wellpoint Essential Silver 5000 Standard ($0 Virtual PCP + $0 Select Drugs + Incentives)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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