DakotaBlue Altru Silver ($5 Value Based Drug List)

Health Insurance Plan Details (2025 Plan)

SBC doc

doctor lookup

drug list

PPO

Silver

Deductible (per individual)	$3,000 /yr
Deductible (per family)	$6,000 /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	PPO
Includes Child Dental?	Yes
Includes Adult Dental?	No

Medical Services
Preventive Care	No Charge
Primary Care Visit	$20 Copay
Specialist Visit	$80 Copay
Emergency Room	40% Coinsurance after deductible
Inpatient Facility	40% Coinsurance after deductible
Inpatient Physician	40% Coinsurance after deductible

Drug Costs
Generic Drugs	$20 Copay
Preferred Brand Drugs	$150 Copay
Non-preferred Brand Drugs	$200 Copay
Specialty Drugs	50% Coinsurance after deductible

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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