The deductible is $250 for single and $500 family coverage. The family deductible is reached from deductible amounts accumulated on behalf of any combination of members. The deductible is waived for services in the office setting from Network providers. All deductibles, copayments, and coinsurance go toward the out-of-pocket maximum. There is a separate out-of-pocket maximum for prescription drugs.
This is a fixed dollar amount you pay each time you receive many covered services. Insureds pay a $15 copayment for office visits.
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 generic preferred drugs
- $15.00 for preferred brand name drugs, and
- $30.00 for non-preferred 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.
This plan also has a mail-order prescription provision that allows you to receive 3 months of a prescription medication while only paying 2 months of co-payments.
This is the amount, using a fixed percentage, you pay each time you receive most covered services. The coinsurance percentage for network providers is 10% and it is 20% for non-network providers. There is 10% coinsurance for emergency room care.
Mental/Nervous/Substance Abuse Coverage
Inpatient: there is 10% coinsurance after the deductible for network providers; 20% coinsurance after the deductible for non-network providers.
Outpatient treatment: $0 co-payment