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BlueSimplicity plan options

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Amounts reflect covered, in-network services only.

Health Care Services BlueSimplicitySM Silver BlueSimplicitySM Gold
Annual benefit — out-of-pocket maximum (opm)1
Single OPM $8,100 $4,750
Family2 OPM $16,200 $9,500
Virtual visit3 $20 $10
Level 1: Preventive care4 Free Free
Level 2: Primary care provider (PCP) office visit5, facility lab/X-ray $60 $35
Level 3: Non- office visit, outpatient PT/OT/ST, home health care, durable medical equipment (DME) $110 $70
Level 4: Emergency room, ground ambulance, diagnostic imaging/studies6 and radiation therapy $600 $500
Level 5: Outpatient practitioner and facility $5,000 $2,500
Level 6: Hospitalization, air ambulance and skilled nursing facility $8,100 $4,000
Prescription drugs - Blue Rx EssentialsSM
Tier 1: Most generics and select branded drugs $30 $25
Tier 2: Preferred drugs based on effectiveness $100 $85
Tier 3: Non-preferred drugs that have cost-effective alternatives $200 $150
Specialty preferred: Proven to treat complex and rare conditions $300 $300
Non-preferred: More beneficial than preferred alternative $500 $500
Medicare Part D Creditable Coverage7 Yes Yes

1 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.
2 The 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.
3 This copay applies to Wellmark’s preferred virtual visit partner, Doctor On Demand.
4 All costs waived when using an in-network or participating provider. Preventive care includes gynecological exams, preventive exams, screening mammography, well-child and newborn visits. One preventive exam with separate gynecological exam per member per benefit period. Well-child visits up to age 7 (includes normal newborn visits, physical examinations, assessments and immunizations.)
5 The 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, 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.
6 Diagnostic imaging includes CT (computerized tomography), MEG (magnetoencephalography), MRAs (magnetic resonance angiography), MRIs (magnetic resonance imaging), PET (positron emission tomography), nuclear medicine and ultrasounds.
7 Medicare Part D creditable coverage status applies for 2021 plan year only.