Wellmark Silver Traditional EPO – EPO
Network type: EPO
Coverage tier: Silver
Primary care visit: $50 copay
Specialist visit: $75 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $5,000 per person $5,000 per person |
| Out-of-pocket max | $8,700 per person $17,400 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $50 copay |
| Specialist visit | $75 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $1,000 copay |
| Ambulance | 30% coinsurance after deductible |
| Hospital stay (facility) | 30% coinsurance after deductible |
| Hospital stay (physician) | 30% coinsurance after deductible |
| Outpatient procedure (facility) | 30% coinsurance after deductible |
| Outpatient procedure (physician) | 30% coinsurance after deductible |
| Physical rehabilitation | 30% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $30 copay |
| Brand | $60 copay |
| Non-preferred Brand | $140 copay |
| Specialty | $300 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 30% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 30% coinsurance after deductible |
| Blood work | 30% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.wellmark.com/-/media/sites/public/files/sbc/sd/PX000006-RX000134.pdf |
| Drug and medication plan formulary | https://wellmark.adaptiverx.com/webSearch/index?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B680B8FCD9DDC119C3C |
| Search doctor list | https://www.wellmark.com/finder-aca |
