Wellpoint

Wellpoint Essential Silver 3500 Adult Dental/Vision ($0 Virtual PCP + $0 Select Drugs + Incentives)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $3,500.00 Family: $7000 Per Person: $3500
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200.00 Family: $18400 Per Person: $9200

Office Visit

Primary Doctor

CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services. 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: $80.00
CoInsurance: Not Applicable
Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Retail Pharmacy is limited to a 30-day supply per Prescription.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Retail Pharmacy is limited to a 30-day supply per Prescription.
Generic Drugs	CoPay: $5.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Retail Pharmacy is limited to a 30-day supply per Prescription.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Specialty Drugs must be purchased from the Pharmacy Benefits Manager?s Specialty Pharmacy and are limited to a 30-day supply.

Inpatient Coverage

Hospital Services	CoPay: $500.00 Copay per Stay after deductible CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $500.00 Copay after deductible CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $500.00 Copay after deductible CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Eye exams are covered once per benefit period. Limit is combined in network and out of network for the exam.

Major Dental Care

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

Coverage provided by Wellpoint Insurance Company.