Care must be completed within 12 months

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.

Pharmacy durable medical equipment (DME) purchased at a retail pharmacy will be subject to your medical DME cost share.

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.

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.

Limit: 1.0 Item(s) per Year

Limited to two spectacle lenses/one frame or contact lenses (in lieu of glasses) per calendar year.

Drugs listed on Wellmark's Blue Rx Essentials Drug List are covered. Drugs not on the Drug List are not covered.

Hospice respite care is limited to 15 inpatient and 15 outpatient days per lifetime.

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.

Applied Behavioral Analysis therapy is covered.

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.

Drugs listed on Wellmark's Blue Rx Essentials Drug List are covered. Drugs not on the Drug List are not covered.

Drugs listed on Wellmark's Blue Rx Essentials Drug List are covered. Drugs not on the Drug List are not covered.

Quantitative limit units apply, see EHB

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.

No limit on covered benefits

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.