Wellmark Bronze Traditional EPO

50305SD0310001
Expanded Bronze
EPO

Wellmark Bronze Traditional EPO is an Expanded Bronze EPO plan by Wellmark of South Dakota, Inc..

IMPORTANT: You are viewing the 2024 version of Wellmark Bronze Traditional EPO 50305SD0310001. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Wellmark Bronze Traditional EPO is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Wellmark Bronze Traditional EPO 50305SD0310001.
Insurer: Wellmark of South Dakota, Inc.
Network Type: EPO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 50305SD0310001

Cost-Sharing Overview

Wellmark Bronze Traditional EPO offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Wellmark Bronze Traditional EPO?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Wellmark Bronze Traditional EPO offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Wellmark Bronze Traditional EPO covers when you are out of the service area or out of the country.

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
National Network: No

Additional Benefits and Cost-Sharing

Wellmark Bronze Traditional EPO includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$80.00 Not ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$150.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$80.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Hospice respite care is limited to 15 inpatient and 15 outpatient days per lifetime.
Routine Dental Services (Adult)
Infertility Treatment
Covered
$80.00 Not ApplicableNot Applicable 100.00%
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$80.00 Not ApplicableNot Applicable 100.00%
Home Health Care Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Emergency Room Services
Covered
$1,200.00 Not Applicable$1,200.00 Not Applicable 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.
Emergency Transportation/Ambulance
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible 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.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% 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.
Bariatric Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Cosmetic Surgery
Skilled Nursing Facility
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% No limit on covered benefits
Prenatal and Postnatal Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$80.00 Not ApplicableNot Applicable 100.00% Applied Behavioral Analysis therapy is covered.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Applied Behavioral Analysis therapy is covered.
Substance Abuse Disorder Outpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$35.00 Not ApplicableNot Applicable 100.00% Drugs listed on Wellmark’s Blue Rx Essentials Drug List are covered. Drugs not on the Drug List are not covered.
Preferred Brand Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% 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
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Drugs listed on Wellmark’s Blue Rx Essentials Drug List are covered. Drugs not on the Drug List are not covered.
Specialty Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% 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.
Outpatient Rehabilitation Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Habilitation Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Chiropractic Care
Covered
$80.00 Not ApplicableNot Applicable 100.00%
Durable Medical Equipment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Pharmacy durable medical equipment (DME) purchased at a retail pharmacy will be subject to your medical DME cost share.
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge Not ApplicableNot Applicable 100.00% Quantitative limit units apply, see EHB
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%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.
Eye Glasses for Children
Covered
Not Applicable 80.00%Not Applicable 100.00%1.0 Item(s) per Year Limited to two spectacle lenses/one frame or contact lenses (in lieu of glasses) per calendar year.
Dental Check-Up for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%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.
Rehabilitative Speech Therapy
Covered
$80.00 Not ApplicableNot Applicable 100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Well Baby Visits and Care
Covered
No Charge Not ApplicableNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Covered
Not Applicable 40.00%Not Applicable 100.00%
Orthodontia – Child
Covered
Not Applicable 60.00%Not Applicable 100.00%
Major Dental Care – Child
Covered
Not Applicable 60.00%Not Applicable 100.00%
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Accidental Dental
Covered
$150.00 Not ApplicableNot Applicable 100.00% Care must be completed within 12 months
Dialysis
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
$150.00 Not ApplicableNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
$80.00 Not ApplicableNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 50.00%Not Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Reconstructive Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Gender Affirming Care

Free Preventive Services

There is no copayment or coinsurance for any of the following Wellmark Bronze Traditional EPO preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Wellmark Bronze Traditional EPO including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Wellmark Bronze Traditional EPO?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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