WellFirst by Medica Silver Copay Plus 100X (Free Virtual Visits) – EPO

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	EPO
Deductible	$100 per person $100 per person
Out-of-pocket max	$750 per person $1,500 per family
Metal tier	Silver

Visit Copay

Primary care visit	$5 copay
Specialist visit	$80 copay
Preventive care visit	No data available

Urgent, Emergency Care, and Hospital Care

Urgent care	$5 copay
Emergency room	$500 copay after deductible, 5% coinsurance after deductible
Ambulance	5% coinsurance after deductible
Hospital stay (facility)	5% coinsurance after deductible
Hospital stay (physician)	5% coinsurance after deductible
Outpatient procedure (facility)	5% coinsurance after deductible
Outpatient procedure (physician)	5% coinsurance after deductible
Physical rehabilitation	$5 copay

Maternitowny and Pregnancy

Well baby care	No data available
Labor, delivery, hospital stay	5% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	$60 copay
Non-preferred Brand	50% coinsurance
Specialty	50% coinsurance

Lab Tests and Diagnostic Procedures

X-rays	5% coinsurance after deductible
Imaging (CT/PET/MRI)	5% coinsurance after deductible
Blood work	5% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$5 copay
Psychiatric hospital stay	5% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://sbc.mo-central.medica.com/api/GetPdfFile/true/WellFirst-MO-by-Medica-Silver-Copay-Plus-100X06_0124.PDF
Drug and medication plan formulary	https://www.Medica.com/WellFirstMODrugList-2024
Search doctor list	https://www.Medica.com/SearchWellFirstMONetwork-2024