Wellmark Bronze Modified HMO Plan Details for 2021- HealthPocket

Wellmark Bronze Modified HMO

$302.90/mo

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Zip Code50317
Applicant10/20/1986 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameWellmark Bronze Modified HMO
Plan IDhhs-25896IA0370001
Plan Year2021
Insurance ProviderWellmark Blue Cross and Blue Shield
Metal LevelExpanded Bronze
Plan TypeHMO
Deductible$8,150
Out-of-Pocket Maximum$8,150
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$85 Copay
Specialist Visit$150 Copay
Laboratory Outpatient and Professional ServicesNo Charge after deductible
X-rays and Diagnostic ImagingNo Charge after deductible
Diagnostic Imaging such as MRIs, CT, and PET scansNo Charge after deductible
Deductible - Family$16300 per group
Out-of-Pocket Maximum - Family$16300 per group

Prescription drug coverage

Generic Drugs$35 Copay
Preferred Brand DrugsNo Charge after deductible
Non-Preferred Brand DrugsNo Charge after deductible
Specialty DrugsNo Charge after deductible

Access to doctors and hospitals

Provider directory URLhttp://www.wellmark.com
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?Yes - Accidental injury and emergency services only
Does this plan cover services outside the country?Yes - Accidental injury and emergency services only

Hospital services

Emergency Room Services$1200 Copay
Inpatient Hospital Services (e.g., Hospital Stay)No Charge after deductible
Inpatient Physician and Surgical ServicesNo Charge after deductible
Emergency Transportation or Ambulance ServiceNo Charge after deductible

Maternity

Prenatal and Postnatal CareNo Charge after deductible
Delivery and all inpatient services for maternity careNo Charge after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$85 Copay
Mental/Behavioral Health Inpatient ServicesNo Charge after deductible
Substance use disorder outpatient services$85 Copay
Substance use disorder inpatient servicesNo Charge after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does this plan offer a wellness program?Included

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsNot Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareNot Covered
Child Dental Coverage - Basic Dental CareNot Covered
Child Dental Coverage - OrthodontiaNot Covered
Child Dental Coverage - Major Dental CareNot Covered

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Skilled Nursing Facility
Bariatric Surgery
Infertility Treatment
Private-Duty Nursing
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Hospice Services
Chiropractic Care
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Prosthetic Devices
Radiation
Reconstructive Surgery
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited Benefits
More Excluded BenefitsAcupuncture
Cosmetic Surgery
Hearing Aids
Long Term Care
Weight Loss Programs
Dental Check-Up for Children
Routine Foot Care
Dental Care - Adult
Abortion for Which Public Funding is Prohibited
Nutritional Counseling
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $449Wellmark Silver Modified HMO$8,150.00Select
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  • Phone Number
    (515) 265-8272
  • Office Locations
    2918 E University Ave
    Des Moines, IA 50317
2918 E University Ave Des Moines IA, 50317

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HealthPocket.com is a free information source. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. While on our site, if you click on a plan or link, you may be directed to one of our partners who offers health insurance products. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.