Skip to main content

BlueSimplicity plan options

With BlueSimplicity, services are grouped into six levels, making it easy for your employees to know their cost share even before receiving services.

  • Level 1 services are free and include preventive services.
  • Level 6 services require higher member copays and cover more serious health needs, such as air ambulance services and hospitalizations.

Amounts in the table reflect covered in-network services only. All plans use Blue Rx Essentials℠ pharmacy benefits.

Plan Details BlueSimplicitySM Silver BlueSimplicitySM Gold
Annual benefit — out-of-pocket maximum (opm) In-network1
Single out-of-pocket maximum $7,900 $4,500
Family2 out-of-pocket maximum $15,800 $9,000
Level 1: Preventive care3 Free Free
Level 2: Primary care provider (PCP) office visit4, facility lab/X-ray, virtual visit5 $50 $30
Level 3: Non-PCP office visit, outpatient PT/OT/ST, home health care, durable medical equipment (DME) $100 $60
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 $7,900 $3,500
Prescription drugs - Blue Rx Essentials
Tier 1 $30 $25
Tier 2 $100 $85
Tier 3 $200 $150
Specialty preferred $300 $300
Non-preferred $500 $500
Medicare Part D Creditable Coverage7 Yes Yes
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 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 All costs waived when using an in-network or participating provider. Preventive care includes gynecological exams, preventive exams, screening mammography, well-child care and newborn care. 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 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.
5 Wellmark’s preferred virtual visit partner is Doctor On Demand.
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 2020 plan year only.