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Wellmark Silver Modified HMOSM

If you want moderate out-of-pocket costs and are unsure how often you’ll visit the doctor, consider a simplified silver plan with no coinsurance.

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 silver tier, overall Wellmark pays about 70 percent and you'll pay about 30 percent of the plan's cost-sharing requirements, which can include the deductible, coinsurance and copays. If you're eligible for cost sharing reduction (CSR), you may pay less for services. Consider a silver plan if you qualify for a CSR, which can help lower your out-of-pocket expenses throughout the year.

Plan Details Wellmark Silver Modified HMOSM
Premium View on 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 care1 Free
Deductible and out-of-pocket maximum Individual: $8,150
Coinsurance - member pays 0%
Virtual visits through Doctor On Demand2 $20
Primary care office services3 $50
Non-primary care office services $75
Emergency room care4 $600
Prescription drugs: Blue Rx EssentialsSM Formulary/CVS Specialty Program Tier 1: $20
Tier 2: $60
Tier 3: $150
Specialty preferred: $300
Non-preferred: $500

Prescription costs matter

With a Wellmark Silver 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.

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

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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 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.