Wellmark Bronze Primary Care | UnityPoint Health – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$7,800 per person $7,800 per person
Out-of-pocket max	$9,000 per person $18,000 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$25 copay
Specialist visit	$110 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$25 copay
Emergency room	50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	50% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$35 copay
Brand	50% coinsurance after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	50% coinsurance after deductible
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	50% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$25 copay
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.wellmark.com/-/media/sites/public/files/sbc/ia/HX000006-RX000121.pdf
Drug and medication plan formulary	https://wellmark.adaptiverx.com/webSearch/index?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B680B8FCD9DDC119C3C
Search doctor list	https://www.wellmark.com/finder-aca