Health Plan Options for Peace of Mind
2021 ACA Plan Comparison Guide | South Dakota Small Group Plans
Make it easy for your employees to know how much a service or procedure will cost before they go for care. BlueSimplicity is an innovative health plan that assigns copays based on the type of service received.
BlueSimplicity plan options
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Amounts reflect covered, in-network services only.
| Health Care Services | BlueSimplicitySM Silver | BlueSimplicitySM Gold |
|---|---|---|
| Annual benefit — out-of-pocket maximum (opm)1 | ||
| Single OPM | $8,100 | $4,750 |
| Family2 OPM | $16,200 | $9,500 |
| Virtual visit3 | $20 | $10 |
| Level 1: Preventive care4 | Free | Free |
| Level 2: Primary care provider (PCP) office visit5, facility lab/X-ray | $60 | $35 |
| Level 3: Non- office visit, outpatient PT/OT/ST, home health care, durable medical equipment (DME) | $110 | $70 |
| Level 4: Emergency room, ground ambulance, diagnostic imaging/studies6 and radiation therapy | $600 | $500 |
| Level 5: Outpatient practitioner and facility | $5,000 | $2,500 |
| Level 6: Hospitalization, air ambulance and skilled nursing facility | $8,100 | $4,000 |
| Prescription drugs - Blue Rx EssentialsSM | ||
| Tier 1: Most generics and select branded drugs | $30 | $25 |
| Tier 2: Preferred drugs based on effectiveness | $100 | $85 |
| Tier 3: Non-preferred drugs that have cost-effective alternatives | $200 | $150 |
| Specialty preferred: Proven to treat complex and rare conditions | $300 | $300 |
| Non-preferred: More beneficial than preferred alternative | $500 | $500 |
| Medicare Part D Creditable Coverage7 | Yes | Yes |
1 Costs for in-network services only apply to the in-network out-of-pocket maximum. Only out-of-pocket costs for out-of-network services apply to the out-of-network out-of-pocket maximum.
2 The family out-of-pocket maximum (OPM) can be met through any combination of family members. No one member will be required to meet more than the single OPM amount to receive benefits for covered services during a benefit period.
3 This copay applies to Wellmark’s preferred virtual visit partner, Doctor On Demand.
4 All costs waived when using an in-network or participating provider. Preventive care includes gynecological exams, preventive exams, screening mammography, well-child and newborn visits. One preventive exam with separate gynecological exam per member per benefit period. Well-child visits up to age 7 (includes normal newborn visits, physical examinations, assessments and immunizations.)
5 The primary care office copay applies to family practitioners, general practitioners, internal medicine practitioners, obstetricians/gynecologists, pediatricians, physicians’ assistants and advanced registered nurse practitioners. This lower office copay also applies to in-network chiropractors, physical therapists, occupational therapists, and in some cases, mental health or chemical dependency visits. All other in-network practitioners are subject to the non-primary care office copay. The copay applies per practitioner, per visit.
6 Diagnostic imaging includes CT (computerized tomography), MEG (magnetoencephalography), MRAs (magnetic resonance angiography), MRIs (magnetic resonance imaging), PET (positron emission tomography), nuclear medicine and ultrasounds.
7 Medicare Part D creditable coverage status applies for 2021 plan year only.
