Wellmark Bronze Traditional HMO Plan Details for 2021- HealthPocket
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Wellmark Bronze Traditional HMO

$302.22/mo
View BrochureSummary of BenefitsProvider Directory

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Zip Code50317
Applicant6/25/1987 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameWellmark Bronze Traditional HMO
Plan IDhhs-25896IA0370005
Plan Year2021
Insurance ProviderWellmark Blue Cross and Blue Shield
Metal LevelExpanded Bronze
Plan TypeHMO
Deductible$7,200
Out-of-Pocket Maximum$8,500
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$75 Copay
Specialist Visit$150 Copay
Laboratory Outpatient and Professional Services50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging50.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans50.00% Coinsurance after deductible
Deductible - Family$14400 per group
Out-of-Pocket Maximum - Family$17000 per group

Prescription drug coverage

Generic Drugs$35 Copay
Preferred Brand Drugs50.00% Coinsurance after deductible
Non-Preferred Brand Drugs50.00% Coinsurance after deductible
Specialty Drugs50.00% Coinsurance 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$950 Copay
Inpatient Hospital Services (e.g., Hospital Stay)50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services50.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service50.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care50.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care50.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$75 Copay
Mental/Behavioral Health Inpatient Services50.00% Coinsurance after deductible
Substance use disorder outpatient services$75 Copay
Substance use disorder inpatient services50.00% Coinsurance 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 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
Weight Loss Programs
Dental Check-Up for Children
Routine Foot Care
Abortion for Which Public Funding is Prohibited
Nutritional Counseling
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $362Medica with CHI Health Bronze Copay$7,000.00Select
from $364Empower by Medica Bronze Copay$7,000.00Select
from $374Elevate by Medica Bronze Copay$7,000.00Select
from $405Medica Insure Bronze Copay$7,000.00Select
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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.

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