Wellmark of South Dakota Inc

Wellmark Silver Traditional EPO

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Combined Medical and Drug Deductible	Individual: $5,000.00 Family: $10000 Per Person: $5000
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,800.00 Family: $15600 Per Person: $7800

Primary Doctor	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered

Preferred Brand Drugs	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Drugs listed on Wellmark's Blue Rx Essentials Drug List are covered. Drugs not on the Drug List are not covered.
Non Preferred Brand Drugs	CoPay: $140.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Drugs listed on Wellmark's Blue Rx Essentials Drug List are covered. Drugs not on the Drug List are not covered.
Generic Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Drugs listed on Wellmark's Blue Rx Essentials Drug List are covered. Drugs not on the Drug List are not covered.
Specialty Drugs	CoPay: $300.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 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.

Hospital Services

Inpatient Services

CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: 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.

Emergency Room	CoPay: $900.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 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.
Urgent Care Facility	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered

Routine Eye Exams for Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year
Benefit Explanation: Vision services apply to members under age 19 and are provided by Avesis participating providers. One diagnostic vision exam per calendar year.

Routine Dental Checkups for Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per 6 Months
Benefit Explanation: 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.