Copayments, Coinsurance, and Out-of-Pocket Maximums - SHIP

Per Service Co-payment/Co-insurance Amounts

Effective Date 01/01/2015-12/31/2015
Provider Tier Blue Cross/Blue Shield Provider
Office Visit $10 co-payment per visit for office visits and $15 co-payment per visit for diagnostic imaging and lab services
Outpatient Facility $50 co-payment per visit for emergency room and 10% co-insurance for surgery
Hospitalization 10% co-insurance after $300 deductible

Out-of-Pocket Maximum (OPM) Expenses for Individuals

In 2015, SHIP providers a $1700 OPM for singles and $3400 for family. In 2015, the OPM for prescriptions is $1000 for a single and $2000 for family.

When the amount paid by the insured equals the OPM, the plan pays 100% of the maximum allowable fee for covered charges. The maximum allowable fee is the amount established by Wellmark using various methodologies for covered services and supplies.