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Wellmark Gold Modified HMOSM for Individuals

If you want lower out-of-pocket expenses with no coinsurance when receiving frequent care, consider a simplified gold plan.

Modified plans provide a simple approach to health insurance and include traditional elements like primary care physician (PCP) copays, but without the coinsurance that comes with a traditional health plan.

With a gold tier, overall Wellmark pays about 80 percent and you'll pay about 20 percent of the plan's cost-sharing requirements, which can include the deductible, coinsurance and copays. Consider a gold plan for lower out-of-pocket costs.

Plan Details Wellmark Gold Modified HMOSM
Premium View on HealthCare.gov External Site
Network: Wellmark Blue HMOSM View in-network providers External SiteEnter your location, browse a list of plans and choose Wellmark Blue HMO.
Preventive care1Free
Deductible and out-of-pocket maximumIndividual: $5,800
Coinsurance - member pays 0%
Virtual visits through Doctor On Demand®2$10
Primary care office services3 $30
Non-primary care office services$70
Emergency room care4$500
Prescription drugs: Blue Rx EssentialsSM Formulary/CVS Specialty® Program Tier 1: $15
Tier 2: $50
Tier 3: $100
Biosimilars: $200
Specialty preferred: $300
Non-preferred: $500

Prescription costs matter

With a Wellmark Gold Modified HMOSM plan, your pharmacy benefits are easy to navigate with Blue Rx EssentialsSM. You'll know exactly what you'll pay without any hidden costs or fees. Search the drug list External Site to check current or anticipated prescriptions.

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

Drug 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 also increases out-of-pocket costs. It consists of non-preferred drugs that have reasonable, more cost-effective alternatives on Tier 1 or Tier 2.

Biosimilar and generic specialty drugs are safe, effective and less costly than specialty treatment options. According to the Food and Drug Administration (FDA), a biosimilar is highly similar to and has no meaningful differences from an existing FDA-approved product.

Specialty drugs are split into two categories — preferred and non-preferred. Preferred drugs are proven to treat complex or rare conditions.

Make sure you write down your plan name! You'll need it to get your premium and enroll.

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1 Preventive care exams (such as annual physical, annual gynecological, and well-child exams), screenings and immunizations must be provided by an in-network doctor.
2 The lower virtual visit copay only applies to Doctor On Demand. All other virtual visits apply the plan's PCP or non-PCP copay.
3 The primary care office copay applies to nurse midwives, 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.
4 Emergency room copay includes physician, facility, labs and X-rays. Copays are waived if admitted as inpatient.
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