Gold health plan options
2023 ACA Plan Comparison Guide | South Dakota Small Group Plans
With a gold tier, overall Wellmark pays about 80 percent and your employees will pay about 20 percent of the plan's cost-sharing requirements, which can include the deductible, coinsurance and copays. Consider a gold plan for lower out-of-pocket expenses for your employees when they receive care.
Gold plan details
All of our members in South Dakota use the Wellmark Blue PPOSM Network which gives them access to more than 1.7 million unique, in-network health care providers throughout the United States1. Amounts in the table reflect covered, in-network services only. All plans include easy-to-navigate pharmacy benefits with Blue Rx EssentialsSM. Blue Rx Essentials prescription tiers are designated based on factors like cost and effectiveness when compared to similar drugs.
| EnhancedBlue 1500 | EnhancedBlue Primary | EnhancedBlue 3000 | |||
|---|---|---|---|---|---|
| Medical deductible — annual amount you pay before Wellmark pays | |||||
| Single | $1,500 | $2,500 | $3,000 | ||
| Family | $3,000 | $5,000 | $6,000 | ||
| Coinsurance — portion of medical cost you pay after your deductible is met | 20% | 25% | 30% | ||
| Out-of-pocket maximum (OPM) — the most you'll spend in a year | |||||
| Single | $6,500 | $5,650 | $6,000 | ||
| Family | $13,000 | $11,300 | $12,000 | ||
| Medical benefits | |||||
| Preventive screenings | Free | Free | Free | ||
| Virtual visits | $0 | $0 | $0 | ||
| Primary care office services | $30 | $10 | $30 | ||
| Non-primary care office services | $60 | $100 | $60 | ||
| Emergency room visits | $500 | Deductible plus 25% coinsurance | $400 | ||
| Outpatient | Deductible plus 20% coinsurance | Deductible plus 30% coinsurance | |||
| Hospitalization | |||||
| Pharmacy benefits — Blue Rx EssentialsSM | |||||
| Preventive | Free | Free | Free | ||
| Tier 1 | $15 | $10 | $15 | ||
| Tier 2 | $50 | Deductible plus 25% coinsurance | $40 | ||
| Tier 3 | $100 | $100 | |||
| Biosimilar and generic specialty | $150 | $160 | |||
| Specialty preferred | $200 | $200 | |||
| Specialty non-preferred | $500 | $400 | |||
| Other benefits | |||||
| Qualifies for health savings account (HSA) | No | No | No | ||
| Medicare Part D Creditable Coverage | Yes | Yes | Yes | ||
| EnhancedBlue 1500 | |||||
|---|---|---|---|---|---|
| Medical deductible — annual amount you pay before Wellmark pays | |||||
| Single | $1,500 | ||||
| Family | $3,000 | ||||
| Coinsurance — portion of medical cost you pay after your deductible is met | 20% | ||||
| Out-of-pocket maximum (OPM) — the most you'll spend in a year | |||||
| Single | $6,500 | ||||
| Family | $13,000 | ||||
| Medical benefits | |||||
| Preventive screenings | Free | ||||
| Virtual visits | $0 | ||||
| Primary care office services | $30 | ||||
| Non-primary care office services | $60 | ||||
| Emergency room visits | $500 | ||||
| Outpatient | Deductible plus 20% coinsurance | ||||
| Hospitalization | |||||
| Pharmacy benefits — Blue Rx EssentialsSM | |||||
| Preventive | Free | ||||
| Tier 1 | $15 | ||||
| Tier 2 | $50 | ||||
| Tier 3 | $100 | ||||
| Biosimilar and generic specialty | $150 | ||||
| Specialty preferred | $200 | ||||
| Specialty non-preferred | $500 | ||||
| Other benefits | |||||
| Qualifies for health savings account (HSA) | No | ||||
| Medicare Part D Creditable Coverage | Yes | ||||
| EnhancedBlue Primary | |||||
|---|---|---|---|---|---|
| Medical deductible — annual amount you pay before Wellmark pays | |||||
| Single | $2,500 | ||||
| Family | $5,000 | ||||
| Coinsurance — portion of medical cost you pay after your deductible is met | 25% | ||||
| Out-of-pocket maximum (OPM) — the most you'll spend in a year | |||||
| Single | $5,650 | ||||
| Family | $11,300 | ||||
| Medical benefits | |||||
| Preventive screenings | Free | ||||
| Virtual visits | $0 | ||||
| Primary care office services | $10 | ||||
| Non-primary care office services | $100 | ||||
| Emergency room visits | Deductible plus 25% coinsurance | ||||
| Outpatient | |||||
| Hospitalization | |||||
| Pharmacy benefits — Blue Rx EssentialsSM | |||||
| Preventive | Free | ||||
| Tier 1 | $10 | ||||
| Tier 2 | Deductible plus 25% coinsurance | ||||
| Tier 3 | |||||
| Biosimilar and generic specialty | |||||
| Specialty preferred | |||||
| Specialty non-preferred | |||||
| Other benefits | |||||
| Qualifies for health savings account (HSA) | No | ||||
| Medicare Part D Creditable Coverage | Yes | ||||
| EnhancedBlue 3000 | |||||
|---|---|---|---|---|---|
| Medical deductible — annual amount you pay before Wellmark pays | |||||
| Single | $3,000 | ||||
| Family | $6,000 | ||||
| Coinsurance — portion of medical cost you pay after your deductible is met | 30% | ||||
| Out-of-pocket maximum (OPM) — the most you'll spend in a year | |||||
| Single | $6,000 | ||||
| Family | $12,000 | ||||
| Medical benefits | |||||
| Preventive screenings | Free | ||||
| Virtual visits | $0 | ||||
| Primary care office services | $30 | ||||
| Non-primary care office services | $60 | ||||
| Emergency room visits | $400 | ||||
| Outpatient | Deductible plus 30% coinsurance | ||||
| Hospitalization | |||||
| Pharmacy benefits — Blue Rx EssentialsSM | |||||
| Preventive | Free | ||||
| Tier 1 | $15 | ||||
| Tier 2 | $40 | ||||
| Tier 3 | $100 | ||||
| Biosimilar and generic specialty | $160 | ||||
| Specialty preferred | $200 | ||||
| Specialty non-preferred | $400 | ||||
| Other benefits | |||||
| Qualifies for health savings account (HSA) | No | ||||
| Medicare Part D Creditable Coverage | Yes | ||||
1 Provider Data Repository (PDR), January 2021. From national BlueCard PPO portion of the network reporting services (NRS) extract of PDR data. The data is limited to records in Plans' licensed service.
Virtual Visits with Doctor On Demand®
Reduce absenteeism and costs while increasing employee satisfaction with virtual visits, included in all our plans. Offered at a lower cost than an office visit, Doctor On Demand allows employees to connect face-to-face with a board-certified doctor or mental health professional from virtually anywhere.
