|
Plan Considerations |
ESSENTIAL |
ENHANCED |
COMPREHENSIVE |
| |
1500 |
600 |
1200 |
1800 |
2400 |
3000 |
4200 |
300 |
750 |
1250 |
1750 |
| Type of Plan |
Preferred Provider Organization (PPO) |
| Provider Directory |
Find a Doctor or Hospital |
Benefit Period
Medical Deductible - You Pay:
Single
Two-Person
Family
|
$1,500
$3,000
$4,500 |
$600
$1,200
$1,800 |
$1,200
$2,400
$3,600 |
$1,800
$3,600
$5,400 |
$2,400
$4,800
$7,200 |
$3,000
$6,000
$9,000 |
$4,200
$8,400
$12,600 |
$300
$600
$900 |
$750
$1,500
$2,250 |
$1,250
$2,500
$3,750 |
$1,750
$3,500
$5,250 |
Coinsurance - You Pay:
Alliance Select Providers
Non-Alliance Sel. Providers |
20%
40% |
20%
40% |
10%
30%
|
Benefit Period
Out-of-Pocket Maximum - You Pay:
Single
Two-Person
Family |
$ 5,500
$11,000
$16,500 |
$1,600
$3,200
$4,800 |
$2,200
$4,400
$6,600 |
$2,800
$5,600
$8,400 |
$3,400
$6,800
$10,200 |
$4,000
$8,000
$12,000 |
$5,200
$10,400
$15,600 |
$1,300
$2,600
$3,900 |
$1,750
$3,500
$5,250 |
$2,250
$4,500
$6,750 |
$2,750
$5,500
$8,250 |
| Lifetime Benefit
Maximum |
$2,000,000 |
Office Visit - You
Pay:
Alliance Select Providers |
$30
copayment; deductible waived |
20% coinsurance; deductible waived |
10% coinsurance; deductible waived |
| Non-Alliance Sel.
Providers |
Deductible followed by 40% coinsurance |
Deductible followed by 40% coinsurance |
Deductible followed by 30% coinsurance |
| Routine Physical
Exams |
Not
covered |
Covered |
Covered |
| Well-child Care
(up to age 7) |
Not
covered |
Covered |
Covered |
Prescription Drugs
Benefit Period Drug Deductible - You Pay: |
BlueRx
|
BlueRx
|
BlueRx
|
|
$500 |
No separate deductible |
$200, waived for Tier 1 or generic drugs |
No separate deductible |
For Tier 1 or generic drugs - You Pay:
|
$10
or 25% of Wellmark's payment arrangement amount, whichever is
greater |
$15 or 25% of Wellmark’s payment arrangement amount, whichever is
greater |
$15 or 25% of Wellmark’s payment arrangement amount, whichever is
greater |
For Tier 2 or specially-selected brand name drugs - You Pay:
|
$20
or 25% of Wellmark's payment arrangement amount, whichever is
greater |
$30 or 25% of Wellmark’s payment arrangement amount, whichever is
greater |
$30 or 25% of Wellmark’s payment arrangement amount, whichever is
greater |
For Tier 3 or all other brand name drugs - You Pay:
|
$20
or 25% of Wellmark's payment arrangement amount, whichever is
greater |
$45 or 25% of Wellmark’s payment arrangement amount, whichever is
greater |
$45 or 25% of Wellmark’s payment arrangement amount, whichever is
greater |
| Maternity |
Complications only |
Complications only |
Covered |
| Chiropractic Care |
Not
covered |
Covered |
Covered |
Mental Health and
Chemical
Dependency Treatment |
Not
covered |
Not covered |
Covered
(see policy limitations) |
| Emergency Room
Copayment |
$75;
waived if admitted |
No copayment |
No copayment |
Out of State
Coverage -
Blue Card Program |
Covered by BlueCard PPO;
Present Alliance Select ID card |
|
$500 Supplemental Accident Option |
Available |
Blue DentalSM (Optional)
Coinsurance - You Pay: |
Available
20% diagnostic, preventive, basic restorative
50% major restorative |
| Benefit Period
Maximum - You Pay: |
$1,000 |