Wellpoint Essential Silver POS 4000 ($0 Virtual PCP + $0 Select Drugs + Incentives)
Wellpoint
Plan overview
Medical deductible
Individual: $4000
Family: $8000
Per Person: $4000
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $9550
Family: $19100
Per Person: $9550
Office visit
Primary Doctor
CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services. 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: $70.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Retail Pharmacy is limited to a 30-day supply per Prescription.
Non preferred brand drugs
CoPay: Not Applicable
CoInsurance: 35.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Retail Pharmacy is limited to a 30-day supply per Prescription.
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: Specialty Drugs must be purchased from the Pharmacy Benefits Manager’s Specialty Pharmacy and are limited to a 30-day supply.
Inpatient coverage
Hospital services
CoPay: $500.00 Copay per Stay after deductible
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: $500.00 Copay after deductible
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Urgent care facility
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: $500.00 Copay after deductible
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal office visit
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Eye exams are covered once per benefit period. Limit is combined in network and out of network for the exam. Limited reimbursement for out of network. You will be responsible for any costs over this limited reimbursement amount.
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).