Wellpoint

Wellpoint Essential Gold 800 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives)

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Combined Medical and Drug Deductible	Individual: $800.00 Family: $1600 Per Person: $800
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,000.00 Family: $18000 Per Person: $9000

Primary Doctor	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: You have $0 virtual visits and medical chats using our preferred virtual care-only Primary Care Physicians (PCP). These services can be accessed via our Sydney application or member website.
Specialist	CoPay: $45.00 CoInsurance: Not Applicable Covered: Covered

Preferred Brand Drugs	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share reflects a 30 day retail supply
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost share reflects a 30 day retail supply
Generic Drugs	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share reflects a 30 day retail supply
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Cost share reflects a 30 day retail supply

Hospital Services

CoPay: $500.00 Copay per Stay after deductible
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis) is limited to a maximum of 60 days per member, per calendar year. Coverage includes inpatient maternity care in a hospital for the mother, and inpatient newborn care in a hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is medically necessary.

Inpatient Services

Emergency Room	CoPay: $500.00 Copay after deductible CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Copay waived if admitted.
Urgent Care Facility	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Urgent Care center services received outside of the service area are not covered, unless the service is rendered at a BlueCard facility. If out of area Urgent Care services are rendered at a BlueCard facility, the cost share is the same as In Network.

Labor and Delivery Hospital Stay

CoPay: $500.00 Copay after deductible
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Coverage includes inpatient maternity care in a Hospital for the mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. Covered services include at-home post delivery care visits at your residence by a Physician or Nurse performed no later than 72 hours following you and your newborn child?s discharge from the hospital.

Pre and Postnatal Office Visit

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Services related to surrogacy are excluded if the member is not the surrogate.

Routine Eye Exams for Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Eye exams are covered once per benefit period. Limit is combined in network and out of network for the exam.

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered

Coverage provided by Simply Healthcare Plans, Inc. doing business as Wellpoint Florida, Inc.