Traditional Health Plans
2019 ACA Plan Comparison Guide for Small Groups | South Dakota
With Wellmark's traditional plans, predictable copays help your employees plan for many common health care expenses, like in-network office visits. For other expenses, like inpatient services, outpatient surgery and maternity care, deductible and coinsurance may apply.
Traditional plan options
|Plan Details||SimplyBlueSM 5500 (Bronze)||CompleteBlueSM 4000 (Silver)||EnhancedBlueSM 2000 (Gold)|
|Annual Benefit — Deductible1|
|Coinsurance — member pays||50%||30%||20%|
|Annual Benefit — Out-of-Pocket Maximum (opm) In-network|
|Single out-of-pocket maximum||$7,900||$7,900||$4,000|
|Family3 out-of-pocket maximum||$15,800||$15,800||$8,000|
|Preventive care4 screenings, immunizations||Free||Free||Free|
|Primary care office visits6||$50||$40||$25|
|Non-primary care office services||Deductible/coinsurance apply||$80||$50|
|Emergency room||Deductible/coinsurance apply||$500||$400|
|Prescription drugs - Blue Rx EssentialsSM|
|Tier 1||For all tiers, deductible/coinsurance apply.||$30||$15|
Blue Rx Essentials SM
Blue Rx Essentials uses tiers to assign drugs' cost share. Tiers are designed based on generics, preferred, non-preferred and specialty drugs.
Drug tier 1
Tier 1 has the lowest payment obligation. It includes most generics and select branded drugs that have no generic equivalent.
Drug tier 2
Tier 2 has a higher payment obligation than Tier 1 and is made up of drugs that are preferred based on effectiveness when compared to similar drugs.
Drug tier 3
Tier 3 also increases the payment obligation. It consists of non-preferred drugs that have reasonable, more cost-effective alternatives on Tier 1 or Tier 2. There are also some specialty preferred drugs in this tier that are used to treat complex or rare conditions.
Specialty drugs are split into two categories: preferred and non-preferred. Preferred drugs are proven to treat complex or rare conditions. Non-preferred drugs have insufficient clinical evidence that they are more beneficial than preferred alternatives.