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Wellmark Bronze Traditional EPO
Health Insurance Plan Details (2024 Plan)
by Wellmark of South Dakota, Inc.
Monthly Premium
EPO
$ubsidy
Bronze
- Deductible
- $7,200 /yr
- Max Out-of-Pocket
- $9,000 /yr
Details
Deductible (per individual) | $7,200 /yr |
Deductible (per family) | $14,400 /yr |
Max Out-of-Pocket (per individual) | $9,000 /yr |
Max Out-of-Pocket (per family) | $18,000 /yr |
Drug Deductible (per individual) | Included in Medical |
Drug Deductible (per family) | Included in Medical |
Drug Max Out-of-Pocket (per individual) | Included in Medical |
Drug Max Out-of-Pocket (per family) | Included in Medical |
Plan Type | EPO |
Includes Child Dental? | Yes |
Includes Adult Dental? | No |
Out-of-Pocket Costs
Preventive Care | No Charge |
Primary Care Visit | $80 Copay |
Specialist Visit | $150 Copay |
Emergency Room | $1,200 Copay |
Inpatient Facility | 50% Coinsurance after deductible |
Inpatient Physician | 50% Coinsurance after deductible |
Generic Drugs | $35 Copay |
Preferred Brand Drugs | 50% Coinsurance after deductible |
Non-preferred Brand Drugs | 50% Coinsurance after deductible |
Specialty Drugs | 50% Coinsurance after deductible |
Plan Documents
Summary of Benefits and Coverage | SBC doc |
Provider Directory | Doctor lookup |
Drug Formulary List | drug list |
* Figures shown are only for in-network medical costs
** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible
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