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Modified health plan options

Modified health plans offer protection from high-cost, catastrophic medical expenses like a hospital stay, while still offering simple copays for the most common services like office visits.

Regardless of the network you choose, all the products below are available. Amounts in the table reflect covered in-network services only. For PPO and POS plans, additional cost-shares will apply to out-of-network services.

All plans use Blue Rx EssentialsSM pharmacy benefits.

Plan Details SimplyBlueSM Modified (Bronze) CompleteBlueSM Modified (Silver) EnhancedBlueSM Modified (Gold)
Annual benefit — deductible/out-of-pocket maximum (opm) In-network1
Single out-of-pocket maximum $8,150 $7,500
Family2 out-of-pocket maximum $16,300 $15,000 $9,000
Coinsurance — member pays 0% 0% 0%
Preventive care3 Free Free Free
Virtual visit4 $75 $50 $30
Primary care office services5 $75 $50 $30
Non-primary care office services $150 $100 $60
Emergency room $1,000 $500 $500
Prescription drugs - Blue Rx EssentialsSM
Tier 1 $20 $30 $20
Tier 2 All other tiers: annual benefit applies $80 $50
Tier 3 $175 $125
Specialty preferred $300 $200
Non-preferred $500 $500
Medicare Part D Creditable Coverage6 No Yes Yes

Your employees will be required to use Blue Distinction® Centers for bariatric surgery and transplants in 2020.

1 Both in-network and out-of-network services apply to a single deductible/OPM. However, out-of-pocket costs for in-network services only apply to the in-network deductible/OPM. Only out-of-network pocket costs for out-of-network services apply to the out-of-network deductible/OPM.
2 The family deductible/OPM can be met through any combination of family members. No one member will be required to meet more than the single deductible amount to receive benefits for covered services during a benefit period.
3 All costs waived when using an in-network or participating provider on PPO plans. On all other available networks, costs are waived when using an in-network provider. Preventive care includes gynecological exam, preventive exam, screening mammography, well-child care and newborn care. For plans on the Wellmark Value Health Plan HMO Network, a designated personal doctor must be seen for preventive care/screenings and immunizations. One preventive exam with separate gynecological exam per member per benefit period. Well-child care up to age 7 (includes normal newborn care, physical examinations, assessments and immunizations.)
4 Wellmark’s preferred virtual visit partner is Doctor On Demand.
The primary care office copay applies to family practitioners, general practitioners, obstetricians/gynecologists, pediatricians, physicians’ assistants and advanced registered nurse practitioners. This lower office copay also applies to in-network chiropractors, physical therapists, occupational therapists, speech pathologists, and in some cases, mental health or chemical dependency visits. All other in-network practitioners are subject to the non-primary care office copay. The copay applies per practitioner, per visit.
Medicare Part D creditable coverage status applies for 2020 plan year only.