Per Service Co-payment/Co-insurance Amounts
|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
SHIP provides a $1,700 OPM for single and $3,400 for family. The OPM for prescriptions is $1,000 for a single and $2,000 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.