Wellmark Bronze HDHP EPO HSA Qualified - 50305SD0310009 Health Insurance Plan
Wellmark of South Dakota health insurance plan with the Plan ID 50305SD0310009. The plan is called Wellmark Bronze HDHP EPO HSA Qualified.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 61.86% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 38.14% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 50305SD0310009 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | South Dakota | ||||||||||||||||||
| Health Insurance Issuer | Wellmark of South Dakota | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 50305SD0310009-03 | ||||||||||||||||||
| Provider Network(s) | BLUERX-ESSENTIALS | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 50305SD0310009-00 Standard On Exchange Plan - 50305SD0310009-01 |
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| Last Plan Update Date | Wed, 09 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Wellmark Bronze HDHP EPO HSA Qualified Health Insurance Plan, 50305SD0310009-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Care must be completed within 12 months |
YES | No Charge after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
100.00% |
| Bariatric Surgery
|
YES | No Charge after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | No Charge after deductible |
100.00% |
| Chemotherapy
|
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
|
YES | No Charge after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months Dental services apply to members under age 19 and are provided by Delta Dental of South Dakota. Limited to twice per calendar year for diagnostic and preventive services. |
YES | No Charge |
100.00% |
| Diabetes Education
|
YES | No Charge after deductible |
100.00% |
| Dialysis
|
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
Pharmacy durable medical equipment (DME) purchased at a retail pharmacy will be subject to your medical DME cost share. |
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
For emergency medical conditions treated out-of-network, it is likely you may not be balance billed pursuant to the federal rules developed for implementation of the No Surprises Act. |
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
For covered non-emergent situations, out-of-network ambulance services are NOT reimbursed at the in-network level. The member may be balance billed for any out-of- network service as established under the rules developed for implementation of the No Surprises Act. |
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Limited to two spectacle lenses/one frame or contact lenses (in lieu of glasses) per calendar year. |
YES | No Charge after deductible |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Drugs listed on Wellmark's Blue Rx Essentials Drug List are covered. Drugs not on the Drug List are not covered. |
YES | No Charge after deductible |
100.00% |
| Habilitation Services
|
YES | No Charge after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
|
YES | No Charge after deductible |
100.00% |
| Hospice Services
Hospice respite care is limited to 15 inpatient and 15 outpatient days per lifetime. |
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
|
YES | No Charge after deductible |
100.00% |
| Infusion Therapy
|
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
When you receive services in an in-network inpatient facility and are provided essential health benefit services by an out-of-network ancillary provider (pathologist, emergency room physician, anesthesiologist, radiologist, or hospitalist), in-network cost-share will be applied and accumulate toward the out-of-pocket maximum. You may be balance billed by the out-of-network ancillary provider. |
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
Applied Behavioral Analysis therapy is covered. |
YES | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Applied Behavioral Analysis therapy is covered. The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | No Charge after deductible |
100.00% |
| Non-Preferred Brand Drugs
Drugs listed on Wellmark's Blue Rx Essentials Drug List are covered. Drugs not on the Drug List are not covered. |
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | No Charge after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Rehabilitation Services
|
YES | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
Drugs listed on Wellmark's Blue Rx Essentials Drug List are covered. Drugs not on the Drug List are not covered. |
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Quantitative limit units apply, see EHB |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | No Charge after deductible |
100.00% |
| Private-Duty Nursing
|
YES | No Charge after deductible |
100.00% |
| Prosthetic Devices
|
YES | No Charge after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
|
YES | No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
|
YES | No Charge after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year Vision services apply to members under age 19 and are provided by Avesis participating providers. One diagnostic vision exam per calendar year. |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
No limit on covered benefits |
YES | No Charge after deductible |
100.00% |
| Specialist Visit
|
YES | No Charge after deductible |
100.00% |
| Specialty Drugs
Specialty drugs are categorized as Biosimilars and Generics, Preferred and Non-Preferred specialty drugs with specific cost-shares attributed to each. Drugs listed on Wellmark's Blue Rx Essentials Drug List are covered. Drugs not on the Drug List are not covered. |
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge after deductible |
100.00% |
| Transplant
|
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
100.00% |
Wellmark Bronze LTD EPO - Ltd AI/AN Health Insurance Plan Variant 50305SD0310009-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.6185780436467839 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | SDF001 |
| Formulary URL | URL |
| HIOS Product ID | 50305SD031 |
| Import Date | 2024-10-09 20:01:46 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 50305 |
| Issuer Marketplace Marketing Name | Wellmark of South Dakota, Inc. |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | SDN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Accidental injury and emergency services only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Accidental injury and emergency services only |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 50305SD0310009-03 |
| Plan Marketing Name | Wellmark Bronze HDHP EPO HSA Qualified |
| Plan Type | EPO |
| Plan Variant Marketing Name | Wellmark Bronze LTD EPO - Ltd AI/AN |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | SDS002 |
| Source Name | SERFF |
| Plan ID | 50305SD0310009 |
| State Code | SD |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $16100 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $8050 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $8,050 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $16100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8050 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,050 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Wellmark Bronze HDHP EPO HSA Qualified Health Insurance Plan, 50305SD0310009
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Wellmark Bronze HDHP EPO HSA Qualified, 50305SD0310009 Health Insurance Plan, 50305SD0310009
-
Does Wellmark Bronze HDHP EPO HSA Qualified Health Insurance Plan, 50305SD0310009 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (50305SD0310009) Health Insurance Plan, Variant (50305SD0310009-03) offer Disease Management Programs?
Does (50305SD0310009) Health Insurance Plan, Variant (50305SD0310009-03) have Out Of Country Coverage?
Does (50305SD0310009) Health Insurance Plan, Variant (50305SD0310009-03) have Out of Service Area Coverage?
Does (50305SD0310009) Health Insurance Plan, Variant (50305SD0310009-03) offer Disease Management Programs?
Does Wellmark Bronze LTD EPO - Ltd AI/AN Health Insurance Plan, Variant (50305SD0310009-03) offer Disease Management Programs for Asthma?
Does Wellmark Bronze LTD EPO - Ltd AI/AN Health Insurance Plan, Variant (50305SD0310009-03) offer Disease Management Programs for Heart disease?
Does Wellmark Bronze LTD EPO - Ltd AI/AN Health Insurance Plan, Variant (50305SD0310009-03) offer Disease Management Programs for Depression?
Does Wellmark Bronze LTD EPO - Ltd AI/AN Health Insurance Plan, Variant (50305SD0310009-03) offer Disease Management Programs for Diabetes?
Does Wellmark Bronze LTD EPO - Ltd AI/AN Health Insurance Plan, Variant (50305SD0310009-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Wellmark Bronze LTD EPO - Ltd AI/AN Health Insurance Plan, Variant (50305SD0310009-03) offer Disease Management Programs for Low back pain?
Does Wellmark Bronze LTD EPO - Ltd AI/AN Health Insurance Plan, Variant (50305SD0310009-03) offer Disease Management Programs for Pregnancy?
Does Wellmark Bronze LTD EPO - Ltd AI/AN Health Insurance Plan, Variant (50305SD0310009-03) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API