Wellmark Silver Traditional EPO

Health Insurance Plan Details (2025 Plan)

by Wellmark of South Dakota, Inc.

Monthly Premium

EPO
$ubsidy
Silver
Deductible
$5,000 /yr
Max Out-of-Pocket
$7,800 /yr

Details

Deductible (per individual) $5,000 /yr
Deductible (per family) $10,000 /yr
Max Out-of-Pocket (per individual) $7,800 /yr
Max Out-of-Pocket (per family) $15,600 /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
Medical Services
Preventive Care No Charge
Primary Care Visit $50 Copay
Specialist Visit $75 Copay
Emergency Room $900 Copay
Inpatient Facility 30% Coinsurance after deductible
Inpatient Physician 30% Coinsurance after deductible
Drug Costs
Generic Drugs $30 Copay
Preferred Brand Drugs $60 Copay
Non-preferred Brand Drugs $140 Copay
Specialty Drugs $300 Copay

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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