Deductibles, Copayments, and Coinsurance - Program 3 Plus

Deductibles

The only place this plan has a deductible is Inpatient hospital services. The deductible is $300 for single and $400 family coverage. The family deductible is reached from deductible amounts accumulated on behalf of any combination of members. For family contracts, the family deductible must be met before benefits are payable for any family member.

Copayments

This is a fixed dollar amount you pay each time you receive many covered services. The Copayment for the exam portion of each office visit on this plan is $15.  Copayments on this plan apply toward your out-of-pocket maximum (OPM).

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 copayment for preferred generic drugs
  • $15.00 copayment for preferred name brand drugs
  • $30.00 copyament 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.

Coinsurance

This is the amount, using a fixed percentage, you pay each time you receive most covered services. The coinsurance percentage for Program 3 Plus is 20%. There is no coinsurance for emergency room care.

Mental/Nervous/Substance Abuse Coverage

Inpatient – there is 20% coinsurance after the deductible.

Outpatient  treatment– no copayment