Copayments and Coinsurance - Blue Access

Insureds will pay a $10 copayment for routine office visits and routine eye and hearing exams. In 2016, there is 10% coinsurance on most services. Insureds will pay 20% coinsurance for durable medical equipment.

When an individual goes to an emergency room, the insured will pay a copayment of $50 - this is waived if the individual is admitted to the hospital.

In 2015, there is no charge for hospital room and board. In 2016, there is a 10% coinsurance.

This plan has a tiered prescription benefit. This means for each prescription you will pay a co-payment, which will vary depending on the tier (or category) of the drug.

Your prescription drug benefits are provided through a three-tier program. This means that you pay a copayment at the time you receive your prescription.   The amount of your copayment is determined by the drug that you receive.

When a 30 day supply of prescription drugs are purchased from participating pharmacies, copayment amounts are:

  • $5.00 for preferred generic drugs
  • $15.00 for preferred brand name drugs, and
  • $30.00 or 25% - whichever is higher for nonpreferred brand name and nonpreferred generic drugs.

If you purchase a brand name drug when an FDA-approved “A”-rated generic equivalent is available, you are responsible for your co-payment or coinsurance, plus any difference between the billed charge for the brand name drug and the billed charge for the generic. This can result in you paying substantially higher costs than if you had chosen the generic drug.

You can search the Wellmark Drug List to determine which tier specific medications are in.