WellFirst by Medica Gold Copay Plus 1500X (Free Virtual Visits) – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $60 copay
Urgent care visit: $30 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,500 per person $1,500 per person |
| Out-of-pocket max | $5,700 per person $11,400 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $60 copay |
| Preventive care visit | No data available |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $30 copay |
| Emergency room | 20% coinsurance after deductible |
| Ambulance | 20% coinsurance after deductible |
| Hospital stay (facility) | 20% coinsurance after deductible |
| Hospital stay (physician) | 20% coinsurance after deductible |
| Outpatient procedure (facility) | 20% coinsurance after deductible |
| Outpatient procedure (physician) | 20% coinsurance after deductible |
| Physical rehabilitation | $30 copay |
Maternitowny and Pregnancy
| Well baby care | No data available |
| Labor, delivery, hospital stay | 20% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $60 copay |
| Non-preferred Brand | $225 copay |
| Specialty | $450 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 20% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 20% coinsurance after deductible |
| Blood work | 20% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://sbc.central.medica.com/api/GetPdfFile/true/WellFirst-IL-by-Medica-Gold-Copay-Plus-1500X01_0124.PDF |
| Drug and medication plan formulary | https://www.Medica.com/ILDrugList-2024 |
| Search doctor list | https://www.Medica.com/SearchWellFirstILNetwork-2024 |
