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Traditional plan options

Plan Details SimplyBlueSM 5500 (Bronze) CompleteBlueSM 4000 (Silver) EnhancedBlueSM 2000 (Gold)
Annual Benefit — Deductible1
Single deductible $5,500 $4,000 $2,000
Family2 deductible $11,000 $8,000 $4,000
Coinsurance — member pays 50% 30% 20%
Annual Benefit — Out-of-Pocket Maximum (opm) In-network
Single out-of-pocket maximum $7,900 $7,900 $4,000
Family3 out-of-pocket maximum $15,800 $15,800 $8,000
Preventive care4 screenings, immunizations Free Free Free
Virtual Visits5 $50 $40 $25
Primary care office visits6 $50 $40 $25
Non-primary care office services Deductible/coinsurance apply $80 $50
Emergency room Deductible/coinsurance apply $500 $400
Prescription drugs - Blue Rx EssentialsSM
Tier 1  For all tiers, deductible/coinsurance apply. $30 $15
Tier 2 $60 $50
Tier 3 $125 $125
Specialty preferred $150 $150
Non-preferred $500 $500

Blue Rx Essentials SM

Blue Rx Essentials uses tiers to assign drugs' cost share. Tiers are designed based on generics, preferred, non-preferred and specialty drugs.

Drug tier 1

Tier 1 has the lowest payment obligation. It includes most generics and select branded drugs that have no generic equivalent.

Drug tier 2

Tier 2 has a higher payment obligation than Tier 1 and is made up of drugs that are preferred based on effectiveness when compared to similar drugs.

Drug tier 3

Tier 3 also increases the payment obligation. It consists of non-preferred drugs that have reasonable, more cost-effective alternatives on Tier 1 or Tier 2. There are also some specialty preferred drugs in this tier that are used to treat complex or rare conditions.

Specialty drugs

Specialty drugs are split into two categories: preferred and non-preferred. Preferred drugs are proven to treat complex or rare conditions. Non-preferred drugs have insufficient clinical evidence that they are more beneficial than preferred alternatives.

1Both in-network and out-of-network services apply toward a single deductible. However, out-of-pocket costs for in-network services only apply to the in-network out-of-pocket maximum. Only out-of-pocket costs for out-of-network services apply to the out-of-network out-of-pocket maximum.
2The family deductible 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.
3The family out-of-pocket maximum (OPM) can be met through any combination of family members. No one member will be required to meet more than the single OPM amount to receive benefits for covered services during a benefit period.
4All 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 ValueSM 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.)
5The virtual visit copay applies to Doctor On DemandTM.
6The primary care office copay applies to family practitioners, general practitioners, internal medicine 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.