WellFirst by Medica Silver Standard 5900X (Free Virtual Visits)
65280IL0010012
Silver
HMO
WellFirst by Medica Silver Standard 5900X (Free Virtual Visits) is a Silver HMO plan by Medica.
IMPORTANT: You are viewing the 2024 version of WellFirst by Medica Silver Standard 5900X (Free Virtual Visits) 65280IL0010012. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.
Locations
WellFirst by Medica Silver Standard 5900X (Free Virtual Visits) is offered in the following counties.
Plan Overview
This is a plan overview for 2024 version of WellFirst by Medica Silver Standard 5900X (Free Virtual Visits) 65280IL0010012.
| Insurer: | Medica |
| Network Type: | HMO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 65280IL0010012 |
Cost-Sharing Overview
WellFirst by Medica Silver Standard 5900X (Free Virtual Visits) offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for WellFirst by Medica Silver Standard 5900X (Free Virtual Visits) includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9100 per person | $18200 per group |
| Deductible: | $5900 per person | $11800 per group |
| Coinsurance: | 40.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for WellFirst by Medica Silver Standard 5900X (Free Virtual Visits) will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $5,900.00 |
| Copayment: | $10.00 |
| Coinsurance: | $2,600.00 |
| Limit: | $60.00 |
| Deductible: | $4,400.00 |
| Copayment: | $300.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $2,100.00 |
| Copayment: | $400.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
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Plan Features
WellFirst by Medica Silver Standard 5900X (Free Virtual Visits) offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Asthma, Heart Disease, Diabetes, Pregnancy |
| Notice Pregnancy: | No |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | See policy or plan document for additional excluded services. |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what WellFirst by Medica Silver Standard 5900X (Free Virtual Visits) covers when you are out of the service area or out of the country.
| Out of Country Coverage: | Yes |
| Out of Country Coverage Description: | Emergency Only |
| Out of Service Area Coverage: | Yes |
| Out of Service Area Coverage Description: | Emergency Only |
| National Network: | No |
Additional Benefits and Cost-Sharing
WellFirst by Medica Silver Standard 5900X (Free Virtual Visits) includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | $40.00 Not Applicable | Not Applicable 100.00% | |
| Specialist Visit Covered | $80.00 Not Applicable | Not Applicable 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $40.00 Not Applicable | Not Applicable 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Hospice Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Residential care; services provided by volunteers; housekeeping or homemaking services; respite care for more than five consecutive days. |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Expenses incurred for cryo preservation or storage of sperm, eggs, and embryos except for those procedures which use a cryo-preserved substance or as required by law; selected termination of an embryo, provided, however, termination will be covered where the mother’s life would be in danger if all embryos were carried to full term; non-medical costs of an egg or sperm donor; travel costs for travel within 100 miles of the member’s home or travel costs not medically necessary; infertility treatments which are deemed experimental or investigational, in writing, by the American Society for Reproductive Medicine or the American College of Obstetricians or Gynecologists; infertility treatment rendered to dependent member under age 18. Limitations vary based on procedures. |
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Private duty nursing services provided by a family member or someone who resides with the member; custodial care or any service that is not required to be provided by a skilled/licensed provider. |
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | $60.00 Not Applicable | $60.00 Not Applicable | |
| Home Health Care Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Residential care; home care services provided by a family member or someone who resides with the member; custodial care or any service that is not required to be provided by a skilled/licensed provider. |
| Emergency Room Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 40.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 40.00% Coinsurance after deductible | Non-emergency or non-urgent ground or air ambulance services or transportation, unless the transportation or service is listed as a covered expense or prior authorized by us; charges for, or in connection with, any other form of travel, unless otherwise stated in this section; member’s condition does not meet medical criteria for ambulance services or transportation; any ambulance transportation or services initiated for convenience or non-medical reasons. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Take home drugs and supplies dispensed by the hospital, unless a written prescription is obtained and filled at a network pharmacy; hospital stays that are extended for reasons other than medical necessity; a continued hospital stay, if the attending health care provider has documented that care could effectively be provided in a less acute care setting; separate charges for personal comfort or convenience items. |
| Inpatient Physician and Surgical Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Bariatric Surgery Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Treatments, services or procedures that are not medically necessary nor approved by us; diet supplements; low-calorie foods and beverages; weight loss books and materials obtained through the program or other outside sources; body sculpting procedures related to weight loss. |
| Cosmetic Surgery Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Cosmetic surgery performed solely for appearance improvement. Coverage includes the functional repair or restoration of any body part when necessary to achieve normal body functioning. |
| Skilled Nursing Facility Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Respite and residential care; any nursing facility services other than skilled nursing services, including intermediate care facilities and community re-entry programs; custodial care; charges for injectable medications administered in a nursing home when we do not cover the nursing home stay; tracheostomy care (if not skilled care); parenteral feeding or tube feeding care. |
| Prenatal and Postnatal Care Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Amniocentesis, CVS (Chorionic Villi Sampling), or non-invasive pre-natal testing when performed exclusively for sex determination; birthing classes; services, drugs or supplies related to abortions, except when a woman suffers from a physical disorder, physical injury, or physical illness that would place the woman in danger of death unless an abortion is performed; home or intentional out-of-hospital deliveries; maternity services received outside the service area during the last 30 days of the pregnancy, except for emergency or urgent care services; treatment, services or supplies for a non-member traditional surrogate or gestational carrier, who is not covered under this policy. |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Amniocentesis, CVS (Chorionic Villi Sampling), or non-invasive pre-natal testing when performed exclusively for sex determination; birthing classes; services, drugs or supplies related to abortions, except when a woman suffers from a physical disorder, physical injury, or physical illness that would place the woman in danger of death unless an abortion is performed; home or intentional out-of-hospital deliveries; maternity services received outside the service area during the last 30 days of the pregnancy, except for emergency or urgent care services; treatment, services or supplies for a non-member traditional surrogate or gestational carrier, who is not covered under this policy. 65280IL0010001-01 – [20.00% Coinsurance after deductible]; 65280IL0010001-02 – [0]; 65280IL0010001-03 – [20.00% Coinsurance after deductible]; 65280IL0010002-01 – [30.00% Coinsurance after deductible]; 65280IL0010002-02 – [0]; 65280IL0010002-03 – [30.00% Coinsurance after deductible]; 65280IL0010002-04 – [30.00% Coinsurance after deductible]; 65280IL0010002-05 – [10.00% Coinsurance after deductible]; 65280IL0010002-06 – [5.00% Coinsurance after deductible]; 65280IL0010003-01 – [No Charge after deductible]; 65280IL0010003-02 – [0]; 65280IL0010003-03 – [No Charge after deductible]; 65280IL0010005-01 – [No Charge after deductible]; 65280IL0010005-02 – [0]; 65280IL0010005-03 – [No Charge after deductible]; 65280IL0010006-01 – [30.00% Coinsurance after deductible]; 65280IL0010006-02 – [0]; 65280IL0010006-03 – [30.00% Coinsurance after deductible]; 65280IL0010006-04 – [20.00% Coinsurance after deductible]; 65280IL0010006-05 – [10.00% Coinsurance after deductible]; 65280IL0010006-06 – [5.00% Coinsurance after deductible]; 65280IL0010007-01 – [No Charge after deductible]; 65280IL0010007-02 – [0]; 65280IL0010007-03 – [No Charge after deductible]; 65280IL0010008-01 – [20.00% Coinsurance after deductible]; 65280IL0010008-02 – [0]; 65280IL0010008-03 – [20.00% Coinsurance after deductible]; 65280IL0010008-04 – [20.00% Coinsurance after deductible]; 65280IL0010008-05 – [5.00% Coinsurance after deductible]; 65280IL0010008-06 – [5.00% Coinsurance after deductible]; 65280IL0010009-01 – [No Charge after deductible]; 65280IL0010009-02 – [0]; 65280IL0010009-03 – [No Charge after deductible]; 65280IL0010010-01 – [No Charge after deductible] |
| Mental/Behavioral Health Outpatient Services Covered | $40.00 Not Applicable | Not Applicable 100.00% | Biofeedback; family counseling for non-medical reasons; wilderness and camp programs, boarding school, academy-vocational programs and group homes; halfway houses; hypnotherapy; long-term or maintenance therapy; marriage counseling; phototherapy. |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Substance Abuse Disorder Outpatient Services Covered | $40.00 Not Applicable | Not Applicable 100.00% | Biofeedback; family counseling for non-medical reasons; wilderness and camp programs, boarding school, academy-vocational programs and group homes; halfway houses; hypnotherapy; long-term or maintenance therapy; marriage counseling; phototherapy. |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Generic Drugs Covered | $20.00 Not Applicable | Not Applicable 100.00% | |
| Preferred Brand Drugs Covered | $40.00 Not Applicable | Not Applicable 100.00% | |
| Non-Preferred Brand Drugs Covered | $80.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Specialty Drugs Covered | $350.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Outpatient Rehabilitation Services Covered | $40.00 Not Applicable | Not Applicable 100.00% | Vocational rehabilitation, including work hardening programs; hearing therapy for communication delay, therapy for perceptual disorders, intellectual disability and related conditions, and other long-term special therapy, except as specifically listed under habilitative services or autism spectrum disorder section; therapy services such as recreational or educational therapy, physical fitness or exercise programs; services to enhance athletic training or performance; services or treatment received at intermediate care facilities; submaximal stress testing except for members with cardiovascular disease. These therapy benefits are only for treatment of those conditions that, in the judgment of the attending health care provider, are expected to yield significant patient improvement, as determined by us. Therapists must be licensed and must not live in the patient’s home or be a family member. |
| Habilitation Services Covered | $40.00 Not Applicable | Not Applicable 100.00% | Custodial care; daycare; recreational care; respite care; vocational or life training. Habilitative Services and devices are those services and devices that help a person keep, learn, or improve skills and functioning for daily living. Covered expenses include medically necessary physical therapy, occupational therapy and speech therapy, counseling, behavioral health services, and services for developmental delay. |
| Chiropractic Care Covered | $40.00 Not Applicable | Not Applicable 100.00% | 25.0 Visit(s) per Benefit Period Maintenance or long-term therapy. |
| Durable Medical Equipment Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Medical supplies and durable medical equipment for comfort, personal hygiene and convenience, regardless of medical necessity of such items; Enteral feedings, unless they are the sole source of nutrition (enteral feedings of standard infant formulas, standard baby food and regular grocery products used in blenderized formulas are excluded regardless of whether they are the sole source of nutrition); Home testing and monitoring supplies and related equipment, except as covered by our medical policy; Equipment, models or devices that have features over and above what is Medically Necessary (Coverage will be limited to the standard model as determined by us); Non-prescription elastic support or anti-embolism stockings; Shoes or foot orthotics not custom-made and purchased over the counter; Any durable medical equipment or supplies used for work, athletic, or job enhancement purposes; Back-up equipment (a second piece); Replacement of durable medical equipment more frequently than every three years, unless defined by our medical policy or mandated by law; Replacement of an item that is lost, stolen, or unusable/nonfunctioning because of misuse, abuse, or neglect; Items that can be purchased over the counter, unless coverage is required by state or federal law; technology devices that are not primarily and customarily used to serve a medical purpose such as desktop computers, portable multi-media players, smart phones, tablet devices and similar items are not considered Durable Medical Equipment. Covers medical supplies and durable medical equipment. Examples include, but are not limited to: wheelchairs, tube feeding nutrition supplies; hospital beds; oxygen and respiratory equipment; walking aids; orthopedic products; urological and ostomy supplies. Oral nutrition (We cover nutritional support that is taken orally (i.e., by mouth) when mandated by law and ordered by a health care provider. Examples include, but are not limited to, donor breast milk and infant formula.). Orthotics and prosthetics. Diabetic durable equipment and insulin infusion pumps (Insulin infusion pumps are limited to one pump per contract period and the member must use the pump for 30 days before purchasing). Other medical supplies as determined by us. |
| Hearing Aids Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 2.0 Item(s) per 2 Years Batteries and chargers for hearing aids. Hearing aids that are available over-the-counter. Limited to one hearing aid per ear or one set of bilateral hearing aids (both ears) and ear molds, including dispensing fees (Benefits are available per Benefit Period. The Benefit Period is 24 consecutive months from the date the benefit is first used). Repairs as medically necessary. The hearing aid must be repaired by/purchased from an authorized provider. Cochlear implants, for children and adults, including procedures for implantation and post-cochlear implant aural therapy. Bone-anchored hearing aids. |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Preventive Care/Screening/Immunization Covered | Not Applicable 0.00% | Not Applicable 100.00% | |
| Routine Foot Care Covered | $80.00 Not Applicable | Not Applicable 100.00% | Podiatry services or routine foot care, except for persons diagnosed with diabetes. These include, but are not limited to: 1) the examination, treatment, or removal of all or part of corns, calluses, hypertrophy or hyperplasia of the skin or subcutaneous tissues of the feet; 2) the cutting, trimming, or other non-operative partial removal of toenails; or 3) any treatment or services in connection with any of these. Only covered for persons diagnosed with diabetes. |
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | $40.00 Not Applicable | Not Applicable 100.00% | 1.0 Exam(s) per Benefit Period Refractive eye surgery and radial keratotomy; contacts lenses (except as a part of cataract surgery or therapeutic contact lenses as defined by us); refractive exams related to contact lenses; any fitting of contact lenses (except for fitting of therapeutic contact lenses as defined by us); refraction aids for low vision and instruction in their use; visual therapy. |
| Eye Glasses for Children Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | 1.0 Item(s) per Benefit Period Blended lenses; replacement of lost, stolen or broken lenses or frames; two pair of glasses as a substitute for bifocals; any vision services, treatment or materials not specifically listed as covered. One pair of prescription eyeglasses per year, as follows: glass or plastic lenses; single vision, lined bifocal and lined trifocal; polycarbonate lenses; frame; contact lenses. Benefits for contact lenses are in lieu of your eyeglass lens benefit. If you receive contact lenses, no benefit will be available for eyeglasses until the next contract period. |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | $40.00 Not Applicable | Not Applicable 100.00% | Vocational rehabilitation, including work hardening programs; hearing therapy for communication delay, therapy for perceptual disorders, intellectual disability and related conditions, and other long-term special therapy, except as specifically listed under habilitative services or autism spectrum disorder section; therapy services such as recreational or educational therapy, physical fitness or exercise programs; services to enhance athletic training or performance; services or treatment received at intermediate care facilities; submaximal stress testing except for members with cardiovascular disease. Medically necessary services resulting from illness or injury; speech and hearing screening examinations to determine the need for correction; post-cochlear implant aural therapy. These therapy benefits are only for treatment of those conditions that, in the judgment of the attending health care provider, are expected to yield significant patient improvement, as determined by us. Therapists must be licensed and must not live in the patient’s home or be a family member. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $40.00 Not Applicable | Not Applicable 100.00% | Vocational rehabilitation, including work hardening programs; hearing therapy for communication delay, therapy for perceptual disorders, intellectual disability and related conditions, and other long-term special therapy, except as specifically listed under habilitative services or autism spectrum disorder section; therapy services such as recreational or educational therapy, physical fitness or exercise programs; services to enhance athletic training or performance; services or treatment received at intermediate care facilities; submaximal stress testing except for members with cardiovascular disease. Medically necessary services resulting from illness or injury; speech and hearing screening examinations to determine the need for correction; post-cochlear implant aural therapy. These therapy benefits are only for treatment of those conditions that, in the judgment of the attending health care provider, are expected to yield significant patient improvement, as determined by us. Therapists must be licensed and must not live in the patient’s home or be a family member. |
| Well Baby Visits and Care Covered | Not Applicable Not Applicable | Not Applicable 100.00% | |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Benefit provided for outpatient services and when these services are related to surgery or medical care. |
| X-rays and Diagnostic Imaging Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Benefit provided for outpatient services and when these services are related to surgery or medical care. |
| Basic Dental Care – Child Not Covered | |||
| Orthodontia – Child Not Covered | |||
| Major Dental Care – Child Not Covered | |||
| Basic Dental Care – Adult Not Covered | |||
| Orthodontia – Adult Not Covered | |||
| Major Dental Care – Adult Not Covered | |||
| Abortion for Which Public Funding is Prohibited Not Covered | |||
| Transplant Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Health services for organ and tissue transplants unless specifically covered under the policy; organ procurement costs for a member who is donating an organ to another person; health services for transplants involving permanent mechanical or animal organs; transplant services that are not performed at an approved facility. |
| Accidental Dental Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Surgery performed to correct functional deformities of the mandible or maxilla; correction of malocclusion; orthognathic surgery; orthodontic care, periodontic care or general dental care; restoration (crowns and root canals are covered only if such treatments are the only clinically acceptable treatments for the trauma/accidental injury); tooth damage due to eating, chewing or biting; These benefits are intended for dental treatment needed to remove, repair, replace, restore and/or reposition sound, natural teeth damaged, lost, or removed due to an injury. The term “injured” does not include conditions resulting from eating, chewing or biting. To be eligible for coverage, the services must be medically necessary while you are enrolled under this policy. The tooth must meet the definition of “sound, natural tooth”. |
| Dialysis Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Allergy Testing Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Chemotherapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Radiation Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Diabetes Education Covered | Not Applicable Not Applicable | Not Applicable 100.00% | Educational services, except for diabetic education. Diabetic education; diabetic self-management training classes. |
| Prosthetic Devices Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Medical supplies and durable medical equipment for comfort, personal hygiene and convenience, regardless of medical necessity of such items; home testing and monitoring supplies and related equipment, except as covered by our medical policy; equipment, models or devices that have features over and above what is medically necessary (Coverage will be limited to the standard model as determined by us); non-prescription elastic support or anti-embolism stockings; shoes or foot orthotics not custom-made and purchased over the counter; any durable medical equipment or supplies used for work, athletic, or job enhancement purposes; back-up equipment (a second piece); replacement of durable medical equipment more frequently than every three years, unless defined by our medical policy or mandated by law; replacement of an item that is lost, stolen, or unusable/nonfunctioning because of misuse, abuse, or neglect; items that can be purchased over the counter, unless coverage is required by state or federal law; technology devices that are not primarily and customarily used to serve a medical purpose such as desktop computers, portable multi-media players, smart phones, tablet devices and similar items are not considered Durable Medical Equipment. |
| Infusion Therapy Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | A drug or biologic that is not considered medically necessary; home infusion administered by a family member or someone who resides with a family member. |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Diagnostic procedures including diagnostic casts, diagnostic study models and bite adjustments and medically necessary surgical or non-surgical treatment for the correction of temporomandibular joint disorders (TMJ), if the following apply: Services are provided under the accepted standards of the profession of the health care provider providing the service; the procedure or device is medically appropriate and appropriate for the diagnosis or treatment of this condition; the purpose of the procedure or device is to control or eliminate infection, pain, disease or dysfunction. Orthognathic surgery only for the treatment of TMJ (prior authorization may be required). |
| Nutritional Counseling Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | A registered or certified dietitian must give or supervise these services. |
| Reconstructive Surgery Covered | Not Applicable 40.00% Coinsurance after deductible | Not Applicable 100.00% | Non-medically necessary plastic surgery (This limitation does not affect coverage provided for breast reconstruction in connection with a mastectomy). Cosmetic services and procedures, including cosmetic surgery. Only includes benefits for mastectomy-related services. |
| Gender Affirming Care |
Free Preventive Services
There is no copayment or coinsurance for any of the following WellFirst by Medica Silver Standard 5900X (Free Virtual Visits) preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for WellFirst by Medica Silver Standard 5900X (Free Virtual Visits) including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
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