Wellpoint Essential Gold 1400 ($0 Virtual PCP + $0 Select Drugs + Incentives)
Wellpoint
Plan overview
Medical deductible
Individual: $1400
Family: $2800
Per Person: $1400
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $5000
Family: $10000
Per Person: $5000
Office visit
Primary Doctor
CoPay: $20.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Cost share applies to both in-person and virtual services from in-network providers. Cost share does not apply to virtual PCP visits from designated virtual care-only providers. If this is an HSA plan, deductible applies.
Specialist
CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Cost share shown is for a 30-day supply.
Non preferred brand drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Cost share shown is for a 30-day supply.
Generic drugs
CoPay: $10.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Cost share reflects a 30 day retail supply. $0 Select Drugs: We offer a $0 cost share for a select set of tier 1 (Generic) prescription drugs. Certain low-cost drugs, on Tier 1, may be available to Members at no Cost Share. These drugs are listed on Our Prescription Drug List (formulary).
Specialty drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Cost share shown is for a 30-day supply.
Inpatient coverage
Hospital services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis) is limited to a maximum of 60 days per member, per calendar year. Coverage includes inpatient maternity care in a hospital for the mother, and inpatient newborn care in a hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is medically necessary.
Inpatient services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Copay is not waived if admitted.
Urgent care facility
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Urgent Care center services received outside of the service area are not covered, unless the service is rendered at a BlueCard facility. If out of area Urgent Care services are rendered at a BlueCard facility, the cost share is the same as In Network.
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Coverage includes inpatient maternity care in a Hospital for the mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary.\n\nCovered services include at-home post delivery care visits at your residence by a Physician or Nurse performed no later than 72 hours following you and your newborn child’s discharge from the hospital.
Pre and Postnatal office visit
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Services related to surrogacy are excluded if the member is not the surrogate.
Vision
Routine Eye Exams for Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit: Exam(s) per Year
Benefit Explanation: Eye exams are covered once per benefit period for INN Services.
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).