IN-NETWORK
BENEFITS |
WELLMARK PPO |
Partial Self-Funded PPO Plan
|
Deductible |
$6,000 Single$12,000 Family |
$1,750 Single$3,500 Family |
Coinsurance |
You pay 20% (after deductible)Plan pays 80% |
You pay 20% (after deductible)Plan pays 80% |
Out of Pocket Maximum |
$8,550 Single$17,100 Family |
$5,000 Single$10,000 Family |
Office Visit Copay |
$25 PCP$25 Specialist$10 Doctor on Demand$30 Urgent Care |
$25 PCP$25 Specialist$10 Doctor on Demand$30 Urgent Care |
Preventive Office Copay |
Covered at 100% |
Covered at 100% |
Emergency Room Copay |
$250 copay |
$250 copay |
Inpatient Hospital or Outpatient Surgery |
You pay 20% after deductible, plan pays 80% |
You pay 20% after deductible
|
Prescription DrugDeductibleCost Per Tier |
$100 Single / $200 Family
|
$100 Single / $200 Family
|






































