The UIChoice Plan provides an annual maximum limit for the out-of-pocket (OPM) expenses for both individuals and families. When the amount paid in co-insurance and deductibles equals the applicable OPM, the plan pays 100% of the covered charges for most additional medically-necessary expenses incurred during the remainder of the calendar year.
|Level 1||Level 2||Level 3|
|Levels 1, 2, and 3 - Blue Card participating providers||$1,700 single/$3,400 family||$1,700 single/$3,400 family||$1,700 single/$3,400 family|
|Non-participating providers||N/A||N/A||$2,000 single/$4,000 family|
|Prescription Drugs||$1,100 single/$2,200 family||$1,100 single/$2,200 family||$1,100 single/$2,200 family|
The OPM for covered expenses received from Levels 1 and 2 and Level 3 participating providers is $1,700 per person and $3,400 per family.
The OPM for Level 3 services is separate from the Level 1 and 2 OPM. The OPM for covered services received from non-participating Level 3 providers is $2,000 per person and $4,000 per family.
The OPM for prescription drugs is $1,100 per person and $2,200 per family.
If a plan member meets the individual OPM, the additional plan member/s continue to pay co-insurance and deductibles until the larger OPM for their contract is met.
The OPM can also be met when no individual plan member meets their individual OPM, but the combination of the out-of-pocket expenses for all the plan members meets the appropriate contract OPM
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The information presented on our website describes only the highlights of the plans and does not constitute official plan documents. Additional terms and conditions may apply. If there are any discrepancies between the information contained herein and the official plan documents, the plan documents will govern. For more detailed information you may contact Wellmark Blue Cross/Blue Shield at toll-free number 800-524-9242 (TTY: 888-781-4262), Monday through Friday from 7:30 a.m. to 5:00 p.m. (Central Time). For more efficient service, please have your member ID number handy - it can be found on the front of your card.