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High-Deductible plan options

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Amounts reflect covered, in-network services only.

Health Care Services myBlue HDHPSM Bronze myBlue HDHPSM Silver
Annual Benefit — Deductible 1
Single deductible $6,900 $4,500
Family2 deductible $13,800 $9,000
Coinsurance — member pays 0% 0%
Annual benefit — Out-of-Pocket Maximum (opm) In-network
Single out-of-pocket maximum $6,900 $6,750
Family3 out-of-pocket maximum $13,800 $13,500
Preventive care4 screenings, immunizations Free Free
Virtual Visit5 Deductible applies $0 after deductible
Primary care office services6 Deductible applies $0 after deductible
Non-primary care office services Deductible applies $60 after deductible
Emergency room Deductible applies $250 after deductible
Prescription drugs - Blue Rx EssentialsSM
Tier 1: Most generics and select branded drugs Deductible applies $20 after deductible
Tier 2: Preferred drugs based on effectiveness $60 after deductible
Tier 3: Non-preferred drugs that have cost-effective alternatives $125 after deductible
Specialty preferred: Proven to treat complex and rare conditions $150 after deductible
Non-preferred: More beneficial than preferred alternative $200 after deductible
Medicare Part D Creditable Coverage7 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 for all plans. 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. One preventive exam with a separate gynecological exam per member per benefit period. 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 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.