Wellmark Standard Gold EPO - 50305SD0310014 Health Insurance Plan
Wellmark of South Dakota health insurance plan with the Plan ID 50305SD0310014. The plan is called Wellmark Standard Gold EPO.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.02% (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 21.98% 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 | 50305SD0310014 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| 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 | 50305SD0310014-00 | ||||||||||||||||||
| 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 - 50305SD0310014-00 Standard On Exchange Plan - 50305SD0310014-01 |
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| Last Plan Update Date | Wed, 16 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Wellmark Standard Gold EPO Health Insurance Plan, 50305SD0310014-00
| 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 | $60.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $60.00 |
100.00% |
| Bariatric Surgery
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | 40.00% |
100.00% |
| Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
|
YES | $30.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance 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 | $30.00 |
100.00% |
| Dialysis
|
YES | 25.00% Coinsurance 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 | 25.00% Coinsurance 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 | 25.00% Coinsurance after deductible |
25.00% Coinsurance 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 | 25.00% Coinsurance after deductible |
25.00% Coinsurance 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 | 80.00% |
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 | $15.00 |
100.00% |
| Habilitation Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Hospice respite care is limited to 15 inpatient and 15 outpatient days per lifetime. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
YES | $30.00 |
100.00% |
| Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance 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 | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | 60.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
Applied Behavioral Analysis therapy is covered. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Applied Behavioral Analysis therapy is covered. |
YES | $30.00 |
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 | $60.00 |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | 60.00% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance 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 | $30.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Quantitative limit units apply, see EHB |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
| Private-Duty Nursing
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
|
YES | 25.00% |
100.00% |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
|
YES | $30.00 |
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 | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $60.00 |
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 | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
100.00% |
| Transplant
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $45.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Wellmark Standard Gold EPO Health Insurance Plan Variant 50305SD0310014-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7801851164396751 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| 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 | SDF004 |
| Formulary URL | URL |
| HIOS Product ID | 50305SD031 |
| Import Date | 2023-08-16 20:01:48 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| 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 | Gold |
| 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 | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 50305SD0310014-00 |
| Plan Marketing Name | Wellmark Standard Gold EPO |
| Plan Type | EPO |
| Plan Variant Marketing Name | Wellmark Standard Gold EPO |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,400 |
| SBC Scenario, Having a Baby, Copayment | $200 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,400 |
| SBC Scenario, Having Diabetes, Deductible | $50 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | SDS002 |
| Source Name | SERFF |
| Plan ID | 50305SD0310014 |
| 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| 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 | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| 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 Standard Gold EPO Health Insurance Plan, 50305SD0310014
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Wellmark Standard Gold EPO, 50305SD0310014 Health Insurance Plan, 50305SD0310014
-
Does Wellmark Standard Gold EPO Health Insurance Plan, 50305SD0310014 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (50305SD0310014) Health Insurance Plan, Variant (50305SD0310014-00) offer Disease Management Programs?
Does (50305SD0310014) Health Insurance Plan, Variant (50305SD0310014-00) have Out Of Country Coverage?
Does (50305SD0310014) Health Insurance Plan, Variant (50305SD0310014-00) have Out of Service Area Coverage?
Does (50305SD0310014) Health Insurance Plan, Variant (50305SD0310014-00) offer Disease Management Programs?
Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310014-00) offer Disease Management Programs for Asthma?
Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310014-00) offer Disease Management Programs for Heart disease?
Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310014-00) offer Disease Management Programs for Depression?
Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310014-00) offer Disease Management Programs for Diabetes?
Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310014-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310014-00) offer Disease Management Programs for Low back pain?
Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310014-00) offer Disease Management Programs for Pregnancy?
Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310014-00) 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