Wellmark Standard Gold EPO - 50305SD0310007 Health Insurance Plan

Wellmark of South Dakota health insurance plan with the Plan ID 50305SD0310007. The plan is called Wellmark Standard Gold EPO.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.00% (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 22.00% 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 50305SD0310007
Health Insurance Plan Year 2023
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 50305SD0310007-00
Provider Network(s) ['SDN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers South Dakota All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 50305SD0310007-00

Standard On Exchange Plan - 50305SD0310007-01

Open to Indians below 300% FPL - 50305SD0310007-02

Open to Indians above 300% FPL - 50305SD0310007-03

Last Plan Update Date Wed, 17 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Wellmark Standard Gold EPO Health Insurance Plan, 50305SD0310007-00

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

$30.00

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

$30.00

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

No Charge

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 50305SD0310007-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.780017779
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
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
First Tier Utilization 100%
Formulary ID SDF001
Formulary URL URL
HIOS Product ID 50305SD031
Import Date 8/17/2022 20:01
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 SDN001
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 1/1/2023
Plan ID (Standard Component ID with Variant) 50305SD0310007-00
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 $2,300
SBC Scenario, Having a Baby, Copayment $200
SBC Scenario, Having a Baby, Deductible $2,000
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 $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,900
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID SDS001
Source Name SERFF
Plan ID 50305SD0310007
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 $4000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $2000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $2,000
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, 50305SD0310007

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Wellmark Standard Gold EPO, 50305SD0310007 Health Insurance Plan, 50305SD0310007

  • Does Wellmark Standard Gold EPO Health Insurance Plan, 50305SD0310007 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (50305SD0310007) Health Insurance Plan, Variant (50305SD0310007-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does (50305SD0310007) Health Insurance Plan, Variant (50305SD0310007-00) have Out Of Country Coverage?

    Yes. Details: Accidental injury and emergency services only

    Does (50305SD0310007) Health Insurance Plan, Variant (50305SD0310007-00) have Out of Service Area Coverage?

    Yes. Details: Accidental injury and emergency services only

    Does (50305SD0310007) Health Insurance Plan, Variant (50305SD0310007-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310007-00) offer Disease Management Programs for Asthma?

    Yes, the Wellmark Standard Gold EPO Health Insurance Plan Variant 50305SD0310007-00 offers Disease Management Program for Asthma.

    Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310007-00) offer Disease Management Programs for Heart disease?

    Yes, the Wellmark Standard Gold EPO Health Insurance Plan Variant 50305SD0310007-00 offers Disease Management Program for Heart disease.

    Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310007-00) offer Disease Management Programs for Depression?

    Yes, the Wellmark Standard Gold EPO Health Insurance Plan Variant 50305SD0310007-00 offers Disease Management Program for Depression.

    Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310007-00) offer Disease Management Programs for Diabetes?

    Yes, the Wellmark Standard Gold EPO Health Insurance Plan Variant 50305SD0310007-00 offers Disease Management Program for Diabetes.

    Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310007-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Wellmark Standard Gold EPO Health Insurance Plan Variant 50305SD0310007-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310007-00) offer Disease Management Programs for Low back pain?

    Yes, the Wellmark Standard Gold EPO Health Insurance Plan Variant 50305SD0310007-00 offers Disease Management Program for Low back pain.

    Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310007-00) offer Disease Management Programs for Pregnancy?

    Yes, the Wellmark Standard Gold EPO Health Insurance Plan Variant 50305SD0310007-00 offers Disease Management Program for Pregnancy.

    Does Wellmark Standard Gold EPO Health Insurance Plan, Variant (50305SD0310007-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Wellmark Standard Gold EPO Health Insurance Plan Variant 50305SD0310007-00 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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