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WellFirst Silver Standard 5800X (Free Virtual Visits & Transportation)

65280IL0010012
Silver
HMO

WellFirst Silver Standard 5800X (Free Virtual Visits & Transportation) is a Silver HMO plan by WellFirst Health.

IMPORTANT: You are viewing the 2023 version of WellFirst Silver Standard 5800X (Free Virtual Visits & Transportation) 65280IL0010012. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

WellFirst Silver Standard 5800X (Free Virtual Visits & Transportation) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of WellFirst Silver Standard 5800X (Free Virtual Visits & Transportation) 65280IL0010012.
Insurer: WellFirst Health
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 65280IL0010012

Cost-Sharing Overview

WellFirst Silver Standard 5800X (Free Virtual Visits & Transportation) offers the following cost-sharing.

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 Standard 5800X (Free Virtual Visits & Transportation)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

WellFirst Silver Standard 5800X (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: Yes
Specialist Requiring Referral: All specialty services with the exception of behavioral health and addiction/substance abuse services
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 Standard 5800X (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 Standard 5800X (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
Hospice Services
Covered
40.00% Coinsurance after deductible 100.00% Residential care; services provided by volunteers; housekeeping or homemaking services.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
40.00% Coinsurance after deductible 100.00% Services or supplies rendered to a surrogate, except that costs for procedures to obtain eggs, sperm, or embryos from the member shall covered if the member chooses to use a surrogate; 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
40.00% Coinsurance after deductible 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 $60.00
Home Health Care Services
Covered
40.00% Coinsurance after deductible 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
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
40.00% Coinsurance after deductible 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.
Primary Care Visit to Treat an Injury or Illness
Covered
$40.00 100.00%
Specialist Visit
Covered
$80.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
40.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
40.00% 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
40.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
40.00% Coinsurance after deductible 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
40.00% Coinsurance after deductible 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
40.00% Coinsurance after deductible 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
40.00% 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, 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
40.00% 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, 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. 65280IL0010011-01 – [25.00% Coinsurance after deductible]; 65280IL0010011-02 – [0]; 65280IL0010011-03 – [25.00% Coinsurance after deductible]; 65280IL0010012-01 – [40.00% Coinsurance after deductible]; 65280IL0010012-02 – [0]; 65280IL0010012-03 – [40.00% Coinsurance after deductible]; 65280IL0010012-04 – [40.00% Coinsurance after deductible]; 65280IL0010012-05 – [30.00% Coinsurance after deductible]; 65280IL0010012-06 – [25.00% Coinsurance]; 65280IL0010013-01 – [50.00% Coinsurance after deductible]; 65280IL0010013-02 – [0]; 65280IL0010013-03 – [50.00% Coinsurance after deductible]; 65280IL0010014-01 – [No Charge after deductible]; 65280IL0010014-02 – [0]; 65280IL0010014-03 – [No Charge after deductible]
Mental/Behavioral Health Outpatient Services
Covered
$40.00 100.00% 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
40.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$40.00 100.00% 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
40.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$20.00 100.00%
Preferred Brand Drugs
Covered
$40.00 100.00%
Non-Preferred Brand Drugs
Covered
$80.00 Copay after deductible 100.00%
Specialty Drugs
Covered
$350.00 Copay after deductible 100.00%
Outpatient Rehabilitation Services
Covered
$40.00 100.00% 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. 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
$40.00 100.00% 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
$40.00 100.00%25 Visit(s) per Benefit Period Maintenance or long-term therapy; cervical pillows; spinal decompression devices.
Durable Medical Equipment
Covered
40.00% 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); 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 or covered under our medical policy for a specific condition 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
40.00% Coinsurance after deductible 100.00%2 Item(s) per 2 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 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
40.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
0.00% 100.00%
Routine Foot Care
Covered
$80.00 100.00% 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
$40.00 100.00%1 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 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; visual therapy.
Eye Glasses for Children
Covered
40.00% Coinsurance after deductible 100.00%1 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.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$40.00 100.00% 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. Medically necessary services resulting from illness or injury; Speech and hearing screening examinations to determine the need for correction; Post-cochlear implant aural therapy; biofeedback (if prior authorization is obtained). 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
$40.00 100.00% 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; biofeedback (if prior authorization is obtained). 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
40.00% Coinsurance after deductible 100.00% Benefit provided for outpatient services and when these services are related to surgery or medical care.
X-rays and Diagnostic Imaging
Covered
40.00% Coinsurance after deductible 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
40.00% Coinsurance after deductible 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
40.00% 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”.
Dialysis
Covered
40.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
40.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
40.00% Coinsurance after deductible 100.00%
Radiation
Covered
40.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
100.00% Educational services, except for diabetic education. Diabetic education; diabetic self-management training classes.
Prosthetic Devices
Covered
40.00% 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); 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
40.00% 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
40.00% 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 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 TMD, when prior authorized by us.
Nutritional Counseling
Covered
40.00% Coinsurance after deductible 100.00% A registered or certified dietitian must give or supervise these services.
Reconstructive Surgery
Covered
40.00% 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. 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 Silver Standard 5800X (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.

Additional Resources

Below are additional resources for WellFirst Silver Standard 5800X (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 Standard 5800X (Free Virtual Visits & Transportation)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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