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Traditional and Modified plan options

  • Traditional health plans — no deductible and coinsurance except for expenses like hospitalizations, outpatient surgery and maternity care.
  • Modified health plans — eliminates coinsurance altogether.

Bronze and Silver plans

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Amounts reflect covered, in-network services only.

Health Care Services SimplyBlueSM 6000 (Bronze) SimplyBlueSM Modified (Bronze) CompleteBlueSM 3500 (Silver) CompleteBlueSM 5000 (Silver) CompleteBlueSM Modified (Silver)
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Annual benefit — deductible1
Single $6,000 $8,400 $3,500 $5,000 $7,700
Family2 $12,000 $16,800 $7,000 $10,000 $15,400
Coinsurance — member pays 50% 0% 30% 30% 0%
Annual benefit — out-of-pocket maximum (opm)1
Single out-of-pocket maximum $8,550 $8,400 $8,00 $8,150 $7,700
Family out-of-pocket maximum3 $17,100 $16,800 $16,000 $16,300 $15,400
Preventive care4 Free Free Free Free Free
Virtual visit5 $30 $30 $20 $20 $20
Primary care office services6 $70 $80 $40 $50 $50
Non-primary care office services Deductible/coinsurance apply $160 $90 $100 $150
Emergency room Deductible/coinsurance apply $1,000 $500 $500 $500
Prescription drugs - Blue Rx EssentialsSM
Tier 1: Most generics and select branded drugs $30 $30 $30 $35 $30
Tier 2: Preferred drugs based on effectiveness All other tiers: deductible/coinsurance applies All other tiers: annual benefit applies $60 $70 $80
Tier 3: Non-preferred drugs that have cost-effective alternatives $125 $140 $175
Specialty preferred: Proven to treat complex and rare conditions $150 $200 $300
Non-preferred: More beneficial than preferred alternative $500 $500 $500
Medicare Part D Creditable Coverage7 No No Yes Yes Yes

Gold plans

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Amounts reflect covered, in-network services only.

Health Care Services EnhancedBlueSM 1500 (Gold) EnhancedBlueSM 3000 (Gold) EnhancedBlueSM Modified (Gold)
Annual benefit — deductible1
Single $1,500 $3,000 $4,600
Family2 $3,000 $6,000 $9,200
Coinsurance — member pays 20% 30% 0%
Annual benefit — out-of-pocket maximum (opm)1
Single out-of-pocket maximum $5,500 $7,000 $4,600
Family out-of-pocket maximum3 $11,000 $14,000 $9,200
Preventive care4 Free Free Free
Virtual visit5 $10 $10 $10
Primary care office services6 $30 $30 $35
Non-primary care office services $60 $60 $70
Emergency room $500 $400 $600
Prescription drugs - Blue Rx EssentialsSM
Tier 1: Most generics and select branded drugs $15 $20 $30
Tier 2: Preferred drugs based on effectiveness $50 $50 $60
Tier 3: Non-preferred drugs that have cost-effective alternatives $100 $125 $150
Specialty preferred: Proven to treat complex and rare conditions $200 $200 $200
Non-preferred: More beneficial than preferred alternative $400 $400 $500
Medicare Part D Creditable Coverage7 No No Yes

1 Both 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.
2 The 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.
3 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.
4 All costs waived when using an in-network or participating provider. Preventive care includes gynecological exam, preventive exam, 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 This copay applies to Wellmark's preferred virtual visit partner, Doctor On Demand.
6 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, 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.
7 Medicare Part D creditable coverage status applies for 2021 plan year only.