WellFirst Silver Copay PCP 4500X (Free Virtual Visits & Transportation)
47840MO0010013
Silver
EPO
WellFirst Silver Copay PCP 4500X (Free Virtual Visits & Transportation) is a Silver EPO plan by WellFirst Health.
IMPORTANT: You are viewing the 2023 version of WellFirst Silver Copay PCP 4500X (Free Virtual Visits & Transportation) 47840MO0010013. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
WellFirst Silver Copay PCP 4500X (Free Virtual Visits & Transportation) is offered in the following counties.
Plan Overview
This is a plan overview for 2023 version of WellFirst Silver Copay PCP 4500X (Free Virtual Visits & Transportation) 47840MO0010013.
| Insurer: | WellFirst Health |
| Network Type: | EPO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 47840MO0010013 |
Cost-Sharing Overview
WellFirst Silver Copay PCP 4500X (Free Virtual Visits & Transportation) offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for WellFirst Silver Copay PCP 4500X (Free Virtual Visits & Transportation) includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9,100.00 | $9100 per person | $18200 per group |
| Deductible: | $4,500.00 | $4500 per person | $9000 per group |
| Coinsurance: | 20.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for WellFirst Silver Copay PCP 4500X (Free Virtual Visits & Transportation) will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | Not Applicable | 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: | $4,500.00 |
| Copayment: | $10.00 |
| Coinsurance: | $1,600.00 |
| Limit: | $60.00 |
| Deductible: | $4,300.00 |
| Copayment: | $300.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $2,400.00 |
| Copayment: | $100.00 |
| 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.
Ready to sign up for WellFirst Silver Copay PCP 4500X (Free Virtual Visits & Transportation)?
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Plan Features
WellFirst Silver Copay PCP 4500X (Free Virtual Visits & Transportation) 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 Silver Copay PCP 4500X (Free Virtual Visits & Transportation) 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 Silver Copay PCP 4500X (Free Virtual Visits & Transportation) 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 | $30.00 | 100.00% | |
| Specialist Visit Covered | 20.00% Coinsurance after deductible | 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $30.00 | 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | 20.00% Coinsurance after deductible | 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | 20.00% Coinsurance after deductible | 100.00% | |
| Hospice Services Covered | 20.00% Coinsurance after deductible | 100.00% | Residential care; services provided by volunteers; housekeeping or homemaking services. |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Not Covered | |||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | 20.00% Coinsurance after deductible | 100.00% | 82 Visit(s) per Benefit Period Private duty nursing services are a covered service only when given as part of the ‘Home Health Care Services’ benefit. Defined as individual and continuous skilled care (in contrast to part-time or intermittent care) of four or more hours; provided according to an individual plan of care, including shift care; and provided by a registered or licensed practical nurse. |
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | 20.00% Coinsurance after deductible | 20.00% Coinsurance after deductible | |
| Home Health Care Services Covered | 20.00% Coinsurance after deductible | 100.00% | 100 Visit(s) per Benefit Period 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. Home care (The attending health care provider must certify that a) hospital confinement, or confinement in a skilled nursing facility, would be needed if home care was not provided; b) the member?s immediate family, or others living with the member, cannot provide the needed care and treatment without undue hardship; and c) a state licensed or Medicare certified home health agency or certified rehabilitation agency will provide or coordinate the home care.); The assessment and development of a home care plan; Physical, respiratory, occupational, behavioral health and addiction, and speech therapy; Medical supplies, drugs and medicines prescribed by a health care provider; Lab services prescribed by a health care provider; Nutritional counseling (a registered or certified dietitian must give or supervise these services); Medications administered in connection with home health care; Private duty nursing. |
| Emergency Room Services Covered | 20.00% Coinsurance after deductible | 20.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | 20.00% Coinsurance after deductible | 20.00% 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 | 20.00% Coinsurance after deductible | 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 | 20.00% Coinsurance after deductible | 100.00% | |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | 20.00% Coinsurance after deductible | 100.00% | 150 Days per Benefit Period 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. Limited to 150 days, combined with inpatient rehabilitative confinement, per member per benefit period. |
| Prenatal and Postnatal Care Covered | 20.00% Coinsurance after deductible | 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 (For the purposes of this exclusion, an elective abortion means an abortion for any reason other than a spontaneous abortion or to prevent the death of the female upon whom the abortion is performed.); Assisted Reproductive Technology (ART) services, treatments, and/or procedures 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 | 20.00% Coinsurance after deductible | 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 (For the purposes of this exclusion, an elective abortion means an abortion for any reason other than a spontaneous abortion or to prevent the death of the female upon whom the abortion is performed.); Assisted Reproductive Technology (ART) services, treatments, and/or procedures for a non-member traditional surrogate or gestational carrier, who is not covered under this policy. 47840MO0010001-01 – [20.00% Coinsurance after deductible]; 47840MO0010001-02 – [0]; 47840MO0010001-03 – [20.00% Coinsurance after deductible]; 47840MO0010002-01 – [30.00% Coinsurance after deductible]; 47840MO0010002-02 – [0]; 47840MO0010002-03 – [30.00% Coinsurance after deductible]; 47840MO0010002-04 – [30.00% Coinsurance after deductible]; 47840MO0010002-05 – [10.00% Coinsurance after deductible]; 47840MO0010002-06 – [5.00% Coinsurance after deductible]; 47840MO0010003-01 – [No Charge after deductible]; 47840MO0010003-02 – [0]; 47840MO0010003-03 – [No Charge after deductible]; 47840MO0010005-01 – [No Charge after deductible]; 47840MO0010005-02 – [0]; 47840MO0010005-03 – [No Charge after deductible]; 47840MO0010006-01 – [30.00% Coinsurance after deductible]; 47840MO0010006-02 – [0]; 47840MO0010006-03 – [30.00% Coinsurance after deductible]; 47840MO0010006-04 – [20.00% Coinsurance after deductible]; 47840MO0010006-05 – [10.00% Coinsurance after deductible]; 47840MO0010006-06 – [5.00% Coinsurance after deductible]; 47840MO0010007-01 – [No Charge after deductible]; 47840MO0010007-02 – [0]; 47840MO0010007-03 – [No Charge after deductible]; 47840MO0010008-01 – [20.00% Coinsurance after deductible]; 47840MO0010008-02 – [0]; 47840MO0010008-03 – [20.00% Coinsurance after deductible]; 47840MO0010008-04 – [20.00% Coinsurance after deductible]; 47840MO0010008-05 – [5.00% Coinsurance after deductible]; 47840MO0010008-06 – [5.00% Coinsurance after deductible]; 47840MO0010009-01 – [No Charge after deductible]; 47840MO0010009-02 – [0]; 47840MO0010009-03 – [No Charge after deductible]; 47840MO0010010-01 – [No Charge after deductible]; 47840MO0010011-01 – [20.00% Coinsurance after deductible]; 47840MO0010011-02 – [0]; 47840MO0010011-03 – [20.00% Coinsurance after deductible]; 47840MO0010012-01 – [20.00% Coinsurance after deductible]; 47840MO0010012-02 – [0]; 47840MO0010012-03 – [20.00% Coinsurance after deductible]; 47840MO0010013-01 – [20.00% Coinsurance after deductible]; 47840MO0010013-02 – [0]; 47840MO0010013-03 – [20.00% Coinsurance after deductible]; 47840MO0010013-04 – [20.00% Coinsurance after deductible]; 47840MO0010013-05 – [20.00% Coinsurance after deductible]; 47840MO0010013-06 – [20.00% Coinsurance after deductible]; 47840MO0010014-01 – [20.00% Coinsurance after deductible]; 47840MO0010014-02 – [0]; 47840MO0010014-03 – [20.00% Coinsurance after deductible] |
| Mental/Behavioral Health Outpatient Services Covered | $30.00 | 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 | 20.00% Coinsurance after deductible | 100.00% | |
| Substance Abuse Disorder Outpatient Services Covered | $30.00 | 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 | 20.00% Coinsurance after deductible | 100.00% | |
| Generic Drugs Covered | $15.00 | 100.00% | |
| Preferred Brand Drugs Covered | 20.00% Coinsurance after deductible | 100.00% | |
| Non-Preferred Brand Drugs Covered | 20.00% Coinsurance after deductible | 100.00% | |
| Specialty Drugs Covered | 20.00% Coinsurance after deductible | 100.00% | |
| Outpatient Rehabilitation Services Covered | $30.00 | 100.00% | 40 Visit(s) per Benefit Period 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. Separate 20 visit(s) limit per therapy type per year for physical and occupational Therapy. Speech therapy is unlimited. 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 | $30.00 | 100.00% | 40 Visit(s) per Benefit Period Custodial care; daycare; recreational care; respite care; vocational or life training. Separate 20 visit(s) limit per therapy type per year for Physical and Occupational Therapy. Speech therapy is unlimited. Habilitative services and devices are those services and devices that help a person keep, learn, or improve skills and functioning for daily living. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
| Chiropractic Care Covered | $30.00 | 100.00% | Maintenance or long-term therapy; cervical pillows; spinal decompression devices. |
| Durable Medical Equipment Covered | 20.00% Coinsurance after deductible | 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); Foods that are naturally low in protein; 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; Oral Nutrition: Oral nutrition is not considered a medical item. We do not cover nutritional support that is taken orally (i.e., by mouth), unless mandated by law or covered under our medical policy for a specific condition. 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; 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); PKU formula and low protein modified food products for the treatment of phenylketonuria or any inherited diseases of amino acids and organic acids; Wigs (scalp prosthesis) following cancer treatment; other medical supplies as determined by us. |
| Hearing Aids Covered | 20.00% Coinsurance after deductible | 100.00% | 2 Item(s) per 3 Years Batteries and chargers for hearing aids. Hearing aids that can be bought without a prescription and the following: a fully implantable middle ear hearing aid; non-implantable, intraoral bone conduction hearing aid. 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 36 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 | 20.00% Coinsurance after deductible | 100.00% | |
| Preventive Care/Screening/Immunization Covered | 100.00% | ||
| Routine Foot Care Covered | 20.00% Coinsurance after deductible | 100.00% | Podiatry services or routine foot care provided when there is no localized illness, injury, or symptoms. 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. Coverage is available if Medically Necessary. |
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | $30.00 | 100.00% | 1 Exam(s) per Benefit Period Refractive eye surgery and radial keratotomy; contact lenses (except as a part of cataract surgery or therapeutic contact lenses as defined by our medical policy); refractive exams related to contact lenses; any fitting of contact lenses (except for fitting of therapeutic contact lenses as defined by our medical policy); refraction aids for low vision and instruction in their use; orthoptics (e.g., eye exercise training), except for convergence disorder; visual therapy. One routine vision exam for children, including dilation and with refraction. |
| Eye Glasses for Children Covered | 20.00% Coinsurance after deductible | 100.00% | 1 Item(s) per Year 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, lined trifocal, lenticular and progressive lenses; polycarbonate lenses; frame; scratch resistant coating; anti-reflective coating; ultraviolet protective coating. 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 | $30.00 | 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. Unlimited visits for speech 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 | $30.00 | 100.00% | 20 Visit(s) per Benefit Period 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. Separate 20 visit(s) limit per therapy type per year for physical and occupational 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 | 100.00% | ||
| Laboratory Outpatient and Professional Services Covered | 20.00% Coinsurance after deductible | 100.00% | |
| X-rays and Diagnostic Imaging Covered | 20.00% Coinsurance after deductible | 100.00% | |
| 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 | 20.00% Coinsurance after deductible | 100.00% | Health services for organ and tissue transplants unless specifically covered under this 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. Services and supplies in connection with covered transplants when prior authorization is not obtained. Any experimental or investigational transplant. Transplants involving non-human or artificial organs. |
| Accidental Dental Covered | 20.00% Coinsurance after deductible | 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”. Coverage is limited to services received within 12 months of the date of the injury. |
| Dialysis Covered | 20.00% Coinsurance after deductible | 100.00% | |
| Allergy Testing Covered | 20.00% Coinsurance after deductible | 100.00% | Cytotoxic testing and sublingual antigens associated to allergy testing. |
| Chemotherapy Covered | 20.00% Coinsurance after deductible | 100.00% | |
| Radiation Covered | 20.00% Coinsurance after deductible | 100.00% | |
| Diabetes Education Covered | 100.00% | Educational services, except for diabetic education and diabetic self-management training classes. Diabetic education; diabetic self-management training classes. | |
| Prosthetic Devices Covered | 20.00% Coinsurance after deductible | 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); Foods that are naturally low in protein; 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. |
| Infusion Therapy Covered | 20.00% Coinsurance after deductible | 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 | 20.00% Coinsurance after deductible | 100.00% | Diagnostic procedures and medically necessary surgical or non-surgical treatment for the correction of temporomandibular disorders (TMD), 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 reasonable 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 TMD, when prior authorized by us; craniomandibular joint services. |
| Nutritional Counseling Covered | 20.00% Coinsurance after deductible | 100.00% | A registered or certified dietitian must give or supervise these services. |
| Reconstructive Surgery Covered | 20.00% Coinsurance after deductible | 100.00% | Non-medically necessary plastic surgery. This limitation does not affect coverage provided for breast reconstruction in connection with a mastectomy. |
| Gender Affirming Care |
Free Preventive Services
There is no copayment or coinsurance for any of the following WellFirst Silver Copay PCP 4500X (Free Virtual Visits & Transportation) 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 Silver Copay PCP 4500X (Free Virtual Visits & Transportation) 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 |
Ready to sign up for WellFirst Silver Copay PCP 4500X (Free Virtual Visits & Transportation)?
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