Attachment G Jefferson Plan SPD FY26.pdf

Group Effective Date: 7/1/2025

Plan Year: July 1

Product ID: PL001921 RL005302

S U M M A R Y P L A N D E S C R I P T I O N

South Dakota State Employee Health Plan

State of South Dakota Jefferson

NOTICE

This group health plan is sponsored and funded by your employer or group sponsor. Your employer or group sponsor has a financial arrangement with Wellmark under which your employer or group sponsor is solely responsible for claim payment amounts for covered services provided to you. Wellmark provides administrative services and provider network access only and does not assume any financial risk or obligation for claim payment amounts.

Form Number: Wellmark SD Grp

Group Effective Date: 7/1/2025

Plan Year: July 1

Print Date: 8/13/2025

Product ID: PL001921 RL005302

Version: 01/25

Wellmark.com

Contents

About This Summary Plan Description

1. What You Pay Payment Summary Payment Details

2. At a Glance - Covered and Not Covered Medical Prescription Drugs

3. Details - Covered and Not Covered Medical Prescription Drugs

4. General Conditions of Coverage, Exclusions, and Limitations Conditions of Coverage General Exclusions Benefit Limitations

5. Choosing a Provider Medical Prescription Drugs

6. Notification Requirements and Care Coordination Medical Prescription Drugs

7. Factors Affecting What You Pay Medical Prescription Drugs

8. Coverage Eligibility and Effective Date Eligible Members Enrollment Requirements Eligibility Requirements When Coverage Begins Late Enrollees Changes to Information Related to You or to Your Benefits Qualified Medical Child Support Order Family and Medical Leave Act of 1993

9. Coverage Changes and Termination Coverage Change Events Requirement to Notify Group Sponsor The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) Coverage Termination Coverage Continuation

10. Claims When to File a Claim How to File a Claim Notification of Decision

11. Coordination of Benefits Other Coverage

Claim Filing Rules of Coordination Coordination with Medicare

12. Appeals Right of Appeal How to Request an Internal Appeal Where to Send Internal Appeal Review of Internal Appeal Decision on Internal Appeal External Review

13. Legal Action

14. General Provisions Contract Interpreting this Summary Plan Description Plan Year Authority to Terminate, Amend, or Modify Authorized Group Benefits Plan Changes Authorized Representative Release of Information Privacy of Information Member Health Support Services Value Added or Innovative Benefits Value-Based Programs Nonassignment Governing Law Medicaid Enrollment and Payments to Medicaid Subrogation and Reimbursement Workers’ Compensation Payment in Error Notice Submitting a Complaint Consent to Telephone Calls and Text or Email Notifications

Glossary

Index

Form Number: Wellmark SD Grp/AM_ 0125 1 PL001921 RL005302

About This Summary Plan Description

Important Information This summary plan description describes your rights and responsibilities under your group health plan. You and your covered dependents have the right to request a copy of this summary plan description, at no cost to you, by contacting your employer or group sponsor.

Please note: Your employer or group sponsor has the authority to terminate, amend, or modify the coverage described in this summary plan description at any time. Any amendment or modification will be in writing and will be as binding as this summary plan description. If your contract is terminated, you may not receive benefits.

You should familiarize yourself with the entire summary plan description because it describes your benefits, payment obligations, provider networks, claim processes, and other rights and responsibilities.

This group health plan consists of medical benefits and prescription drug benefits. The medical benefits are called Blue Select. The prescription drug benefits are called Blue Rx Value Plus. This summary plan description will indicate when the service, supply, or drug is considered medical benefits or drug benefits by using sections, headings, and notes when necessary.

Charts Some sections have charts, which provide a quick reference or summary but are not a complete description of all details about a topic. A particular chart may not describe some significant factors that would help determine your coverage, payments, or other responsibilities. It is important for you to look up details and not to rely only upon a chart. It is also important to follow any references to other parts of the summary plan description. (References tell you to

“see” a section or subject heading, such as, “See Details – Covered and Not Covered.”

References may also include a page number.)

Complete Information Very often, complete information on a subject requires you to consult more than one section of the summary plan description. For instance, most information on coverage will be found in these sections:

◼ At a Glance – Covered and Not Covered

◼ Details – Covered and Not Covered

◼ General Conditions of Coverage, Exclusions, and Limitations

However, coverage might be affected also by your choice of provider (information in the

Choosing a Provider section), certain notification requirements if applicable to your group health plan (the Notification Requirements and Care Coordination section), and considerations of eligibility (the Coverage Eligibility and Effective Date section).

Even if a service is listed as covered, benefits might not be available in certain situations, and even if a service is not specifically described as being excluded, it might not be covered.

Read Thoroughly You can use your group health plan to the best advantage by learning how this document is organized and how sections are related to each other. And whenever you look up a particular topic, follow any references, and read thoroughly.

About This Summary Plan Description

PL001921 RL005302 2 Form Number: Wellmark SD Grp/AM_ 0125

Your coverage includes many services, treatments, supplies, devices, and drugs. Throughout the summary plan description, the words services or supplies refer to any services, treatments, supplies, devices, or drugs, as applicable in the context, that may be used to diagnose or treat a condition.

Plan Description Plan Name: South Dakota State Employee Health Plan Plan Sponsor: Administered by the Commissioner of the Bureau of Human Resources and

Administration of the State of South Dakota Employer ID Number: 46-6000364 When Plan Year Ends: June 30 Participants of Plan: See Coverage Eligibility and Effective Date later in this summary plan description.

Plan Administrator and Agent for Service of Legal Process:

Bureau of Human Resources and Administration

Attn: Bureau of Human Resources and Administration

500 East Capitol Ave

Pierre,SD 57501

Phone Number: 605-773-3148

Service of legal process may be made upon the plan administrator and/or agent.

How Plan Costs Are Funded: Self Funded Type of Plan: Group Health Plan Type of Administration: Self-Funded Benefits Administered by: Wellmark Blue Cross and Blue Shield of South Dakota

1601 W Madison Street

Sioux Falls, SD 57104-5710

If this plan is maintained by two or more employers, you may write to the plan administrator for a complete list of the plan sponsors.

Questions If you have questions about your group health plan, or are unsure whether a particular service or supply is covered, call the Customer Service number on your ID card.

Form Number: Wellmark SD Grp/WYP_ 0125 3 PL001921 RL005302

1. What You Pay

This section is intended to provide you with an overview of your payment obligations under this group health plan. This section is not intended to be and does not constitute a complete description of your payment obligations. To understand your complete payment obligations you must become familiar with this entire summary plan description, especially the Factors

Affecting What You Pay and Choosing a Provider sections.

Provider Network Under the medical benefits of this plan, your network of providers consists of PPO and

Participating providers. All other providers are Out-of-Network Providers. Which provider type you choose will affect what you pay.

In-Network Providers PPO Providers. These providers participate with the Wellmark Blue PPOSM network or with a Blue Cross and/or Blue Shield PPO network in another state or service area. You typically pay the least for services received from these providers. Throughout this summary plan description we refer to these providers as “in-network providers” or PPO Providers.

Participating Providers. These providers participate with a Blue Cross and/or Blue

Shield Plan in another state or service area, but not with a PPO network. You typically pay more for services from these providers than for services from PPO Providers. Throughout this summary plan description we refer to these providers as Participating Providers.

Out-of-Network Providers Out-of-Network Providers. Out-of-Network Providers do not participate with Wellmark or any other Blue Cross and/or Blue Shield Plan. You typically pay the most for services from these providers. Throughout this document we refer to these providers as Out-of-Network

Providers.

Payment Summary This chart summarizes your payment responsibilities. It is only intended to provide you with an overview of your payment obligations. It is important that you read this entire section and not just rely on this chart for your payment obligations.

Medical

You Pay

Deductible

$2,000 per person for covered services received from PPO Providers.

$4,000 (maximum) per family* for covered services received from PPO Providers.

$3,750 per person for covered services received from Participating and Out-of- Network providers.

$7,500 (maximum) per family* for covered services received from Participating and Out-of-Network providers.

Emergency Room Copayment

$250 followed by coinsurance

What You Pay

PL001921 RL005302 4 Form Number: Wellmark SD Grp/WYP_ 0125

You Pay

Office Visit Copayment

$50 for:

◼ covered services received from PPO primary care practitioners ◼ covered services received from PPO chiropractors ◼ covered services received from PPO occupational therapists ◼ covered services received from PPO physical therapists ◼ covered mental health and chemical dependency treatment received in an office setting from PPO Providers $100 for covered services received from PPO non-primary care practitioners.

Telehealth Services Copayment

$50 for covered telehealth services received from practitioners contracting through Doctor on Demand§.

$50 for:

◼ covered telehealth services received from PPO primary care practitioners ◼ covered telehealth services received from PPO chiropractors ◼ covered telehealth services received from PPO occupational therapists ◼ covered telehealth services received from PPO physical therapists ◼ covered telehealth mental health and chemical dependency treatment received from PPO practitioners $100 for covered telehealth services received from PPO non-primary care practitioners.

Urgent Care Center Copayment

$50 for covered services received from PPO Providers in South Dakota or Iowa classified by Wellmark as Urgent Care Centers and covered urgent care services received from PPO urgent care facilities or clinics outside of South Dakota or Iowa.†

Coinsurance

30% for covered services received from PPO Providers.

40% for covered services received from Participating and Out-of-Network providers.

Out-of-Pocket Maximum

$4,500 per person for covered services received from PPO and Participating providers. This includes amounts you pay for covered drugs.

$9,000 (maximum) per family* for covered services received from PPO and Participating providers. This includes amounts you pay for covered drugs.

$8,500 per person for covered services received from Out-of-Network Providers.

$17,000 (maximum) per family* for covered services received from Out-of-Network Providers.

*Family amounts are reached from amounts accumulated on behalf of any combination of covered family members. A member will not be required to satisfy more than the single deductible before we make benefit payments for that member.

†For a list of South Dakota or Iowa facilities classified by Wellmark as Urgent Care Centers, please see the Wellmark Provider Directory.

§Members can access telehealth services from Doctor on Demand through the Doctor on Demand mobile application or through myWellmark.com.

Please note: Out-of-pocket maximum amounts you pay for covered medical benefits under Blue Select also apply toward the Blue Rx Value Plus out-of-pocket maximum. Likewise, out-of-pocket maximum amounts you pay for covered prescription drug benefits under Blue Rx Value Plus apply toward the Blue Select medical out-of-pocket maximum.

http://mywellmark.com/

Form Number: Wellmark SD Grp/WYP_ 0125 5 PL001921 RL005302

Prescription Drugs

You Pay†

Coinsurance or Copayment

$25 for Tier 1 medications.

$65 for:

◼ Tier 2 medications.

◼ Continuous glucose monitors purchased at a pharmacy.

$150 for Tier 3 medications.

For more information see Tiers, page 70.

$300 for preferred specialty drugs, including biosimilars and generics, not listed on the PrudentRx drug list.

$450 for non-preferred specialty drugs not listed on the PrudentRx drug list.

30% for prescription drugs listed on the PrudentRx drug list. (If you enroll with PrudentRx to get copayment assistance for your eligible specialty medications, you will have $0 out-of-pocket responsibility for prescriptions listed on the PrudentRx drug list.) Drugs designated as ‘specialty medical’ on the Blue Rx Value Plus Drug List that are administered or infused by a healthcare provider in an office setting will be processed under the medical benefits of your summary plan description.

30% for pharmacy durable medical equipment devices received from participating pharmacies.

40% for pharmacy durable medical equipment devices received from nonparticipating pharmacies.

Out-of-Pocket Maximum

$4,500 per person $9,000 (maximum) per family*

*Family amounts are reached from amounts accumulated on behalf of any combination of covered family members.

†You pay the entire cost if you purchase a drug or pharmacy durable medical equipment device that is not on the Wellmark Blue Rx Value Plus Drug List. See Wellmark Blue Rx Value Plus Drug List, page 39.

Please note: Out-of-pocket maximum amounts you pay for covered prescription drug benefits under Blue Rx Value Plus also apply toward the Blue Select medical out-of-pocket maximum. Likewise, out-of-pocket maximum amounts you pay for covered medical benefits under Blue Select apply toward the Blue Rx Value Plus out-of-pocket maximum. If you do not enroll in the PrudentRx program, any coinsurance you pay for specialty medications listed on the PrudentRx drug list that do not qualify as Essential Health Benefits under the Affordable Care Act will not count toward either your medical or prescription drug deductible or out-of-pocket maximum.

Prescription Maximums Generally, there is a maximum days' supply of medication you may receive in a single prescription. However, exceptions may be made for certain prescriptions packaged in a dose exceeding the maximum days' supply covered under your Blue Rx Value Plus prescription drug benefits. To determine if this exception applies to your prescription, call the Customer Service number on your ID card.

Your payment obligations may be determined by the quantity of medication you purchase.

Payment

90 day retail

Payment per days' supply:

1 copayment for 30 day supply

2.5 copayments for 90 day supply

90 day mail order

Payment per days' supply:

1 copayment for 30 day supply

2.5 copayments for 90 day supply

30 day specialty

1 copayment

PL001921 RL005302 6 Form Number: Wellmark SD Grp/WYP_ 0125

Payment Details

Medical

Deductible This is a fixed dollar amount you pay for covered services in a benefit year before medical benefits become available.

The family deductible amount is reached from amounts accumulated on behalf of any combination of covered family members.

A member will not be required to satisfy more than the single deductible before we make benefit payments for that member.

Deductible amounts you pay will not start over on facility charges if an inpatient hospital stay extends from one benefit year to the next. Deductible amounts incurred after discharge will apply to the new plan year benefits.

Deductible amounts you pay for PPO or

Participating and Out-of-Network provider services apply toward meeting both the PPO and the Participating/Out-of-Network deductibles. The maximum deductible amount you pay is the Participating/Out-of-

Network deductible.

If you do not enroll in the PrudentRx program, any deductible amounts you pay for drugs listed on the PrudentRx drug list that do not qualify as Essential Health

Benefits under the Affordable Care Act will not count toward your medical deductible.

Once you meet the deductible, then coinsurance applies.

When the No Surprises Act applies, you may not be required to satisfy your entire deductible before we make benefit payments, amounts you pay for items and services will accumulate toward your PPO deductible, and you may not be billed for more than the amount you would pay if the services had been provided by a

Participating Provider. The No Surprises

Act applies to emergency services at an Out-of-Network facility, items and services from

Out-of-Network Providers related to visits to certain participating facilities, and Out-of-Network air ambulance services.

Deductible amounts are waived for some services. See Waived Payment Obligations later in this section.

Copayment This is a fixed dollar amount that you pay each time you receive certain covered services.

Emergency Room Copayment.

The emergency room copayment:

◼ applies to emergency room services.

◼ is taken once per visit.

◼ is waived if you are admitted as an inpatient of a facility immediately following emergency room services.

Office Visit Copayment.

The office visit copayment:

◼ applies to covered office services received from PPO practitioners.

Separate facility services are subject to deductible and coinsurance.

◼ is taken once per practitioner per date of service.

Please note: For purposes of determining your copayment responsibility, PPO

Providers are classified by Wellmark as either primary care practitioners or non-primary care practitioners. To determine whether the primary care practitioner copayment or the non-primary care practitioner copayment applies, you should call the Customer Service number on your

ID card before receiving any services to determine whether your provider is classified by Wellmark as a primary care practitioner or a non-primary care practitioner for purposes of your copayment responsibility.

How providers are classified in the

Wellmark Provider Directory does not

Form Number: Wellmark SD Grp/WYP_ 0125 7 PL001921 RL005302 determine whether a provider is a primary care practitioner or a non-primary care practitioner for purposes of your copayment responsibility. For example, a provider might be listed under multiple specialties in the provider directory, such as internal medicine and oncology, but would be classified by Wellmark as a primary care practitioner for purposes of your copayment responsibility.

A primary care practitioner is a PPO:

◼ advanced registered nurse practitioner

(ARNP)

◼ certified nurse midwife

◼ family practitioner

◼ general practitioner

◼ geriatrician

◼ internal medicine practitioner

◼ obstetrician/gynecologist

◼ pediatrician

◼ physician assistant (PA)

All other PPO practitioners are non-primary care practitioners. See Choosing a Provider, page 49.

Related laboratory services received from a

PPO independent lab are subject to deductible and coinsurance and not this copayment.

Telehealth Services Copayment.

The telehealth services copayment:

◼ applies to covered telehealth services received from PPO practitioners and practitioners contracting through

Doctor on Demand.

◼ is taken once per practitioner per date of service.

Please note: For purposes of determining your copayment responsibility, PPO

Providers are classified by Wellmark as either primary care practitioners or non-primary care practitioners. To determine whether the primary care practitioner copayment or the non-primary care practitioner copayment applies, you should call the Customer Service number on your

ID card before receiving any services to determine whether your provider is classified by Wellmark as a primary care practitioner or a non-primary care practitioner for purposes of your copayment responsibility. Doctor on Demand is not a

PPO practitioner, so will apply a separate copayment responsibility.

How providers are classified in the

Wellmark Provider Directory does not determine whether a provider is a primary care practitioner or a non-primary care practitioner for purposes of your copayment responsibility. For example, a provider might be listed under multiple specialties in the provider directory, such as internal medicine and oncology, but would be classified by Wellmark as a primary care practitioner for purposes of your copayment responsibility.

A primary care practitioner is a PPO:

◼ advanced registered nurse practitioner

(ARNP)

◼ certified nurse midwife

◼ family practitioner

◼ general practitioner

◼ geriatrician

◼ internal medicine practitioner

◼ obstetrician/gynecologist

◼ pediatrician

◼ physician assistant (PA)

All other PPO practitioners are non-primary care practitioners. See Choosing a Provider, page 49.

Urgent Care Center Copayment.

The urgent care center copayment:

◼ applies to covered urgent care services received from:

⎯ PPO Providers in South Dakota or

Iowa classified by Wellmark as

Urgent Care Centers.

⎯ PPO urgent care facilities or clinics outside of South Dakota or Iowa.

◼ is taken once per provider per date of service.

Please note: If you receive care at a facility in South Dakota or Iowa that is not

PL001921 RL005302 8 Form Number: Wellmark SD Grp/WYP_ 0125 classified by Wellmark as an Urgent Care

Center, you may be responsible for your deductible and coinsurance (as applicable) instead of the urgent care center copayment.

Therefore, before receiving any urgent care services, you should determine if the facility is classified by Wellmark as an Urgent Care

Center. See the Wellmark Provider

Directory at Wellmark.com/member/find-provider or call the Customer Service number on your ID card to determine whether a facility is classified by Wellmark as an Urgent Care Center.

Copayment amount(s) are waived for some services. See Waived Payment Obligations later in this section.

Coinsurance Coinsurance is an amount you pay for certain covered services. Coinsurance is calculated by multiplying the fixed percentage(s) shown earlier in this section times Wellmark’s payment arrangement amount. Payment arrangements may differ depending on the contracting status of the provider and/or the state where you receive services. For details, see How Coinsurance is Calculated, page 65. Coinsurance amounts apply after you meet the deductible and any applicable copayments.

Coinsurance amounts are waived for some services. See Waived Payment Obligations later in this section.

Out-of-Pocket Maximum The out-of-pocket maximum is the maximum amount you pay, out of your pocket, for most covered services in a benefit year. Many amounts you pay for covered services during a benefit year accumulate toward the out-of-pocket maximum. These amounts include:

◼ Deductible.

◼ Coinsurance.

◼ Emergency room copayments.

◼ Office visit copayments.

◼ Telehealth services copayments.

◼ Urgent care center copayments.

◼ Amounts you pay for covered prescription drugs.

The family out-of-pocket maximum is reached from applicable amounts paid on behalf of any combination of covered family members.

A member will not be required to satisfy more than the single out-of-pocket maximum.

Out-of-pocket maximum amounts you pay will not start over on facility charges if an inpatient hospital stay extends from one benefit year to the next. Out-of-pocket maximum amounts incurred after discharge will apply to the new plan year benefits.

Out-of-pocket maximum amounts you pay for covered medical benefits under Blue

Select also apply toward the Blue Rx Value

Plus out-of-pocket maximum. Likewise, out-of-pocket maximum amounts you pay for covered prescription drug benefits under

Blue Rx Value Plus apply toward the Blue

Select medical out-of-pocket maximum.

There is an out-of-pocket maximum for services you receive from PPO Providers and Participating Providers. There is also an out-of-pocket maximum for services you receive from Out-of-Network Providers.

These out-of-pocket maximums accumulate to one another.

If you do not enroll in the PrudentRx program, any out-of-pocket maximum amounts you pay for drugs listed on the

PrudentRx drug list that do not qualify as

Essential Health Benefits under the

Affordable Care Act will not count toward either your medical or prescription drug out-of-pocket maximum.

However, certain amounts do not apply toward your out-of-pocket maximum.

◼ Amounts representing any general exclusions and conditions. See General

Conditions of Coverage, Exclusions, and

Limitations, page 43.

◼ Difference in cost between the generic drug and the brand name drug when you purchase a brand name drug that

Form Number: Wellmark SD Grp/WYP_ 0125 9 PL001921 RL005302 has an FDA-approved “A”-rated medically appropriate generic equivalent.

◼ Difference in cost between the provider’s amount charged and our maximum allowable fee when you receive services from an Out-of-Network Provider.

These amounts continue even after you have met your out-of-pocket maximum.

When the No Surprises Act applies, amounts you pay for items and services will accumulate toward your PPO out-of-pocket maximum and you may not be billed for more than the amount you would pay if the services had been provided by a

Participating Provider. The No Surprises

Act applies to emergency services at an Out-of-Network facility, items and services from

Out-of-Network Providers related to visits to certain participating facilities, and Out-of-Network air ambulance services.

Benefits Maximums Benefits maximums are the maximum benefit amounts that each member is eligible to receive.

Benefits maximums that apply per benefit year or per lifetime are reached from benefits accumulated under this group health plan and any prior group health plans sponsored by your employer or group sponsor and administered by Wellmark

Blue Cross and Blue Shield of South Dakota.

No Surprises Act When the No Surprises Act applies, the amount you pay will be determined in accordance with the Act and you may not be billed for more than the amount you would pay if the services had been provided by a

Participating Provider. The No Surprises

Act applies to emergency services at an Out-of-Network facility, items and services from

Out-of-Network Providers related to visits to certain participating facilities, and Out-of-Network air ambulance services.

Waived Payment Obligations To understand your complete payment obligations you must become familiar with this entire summary plan description. Most information on coverage and benefits maximums will be found in the At a Glance – Covered and Not Covered and Details – Covered and Not Covered sections.

Some payment obligations are waived for the following covered services.

Covered Service Payment Obligation Waived

Breast pumps (manual or non-hospital grade electric) purchased from a covered PPO or Participating home/durable medical equipment provider.

Deductible

Coinsurance

Copayment

Breastfeeding support, supplies, and one-on-one lactation consultant services, including counseling and education, during pregnancy and/or the duration of breastfeeding when received from PPO or Participating providers.

Deductible

Coinsurance

Copayment

Certain office services received from PPO Providers. Deductible

Coinsurance

PL001921 RL005302 10 Form Number: Wellmark SD Grp/WYP_ 0125

Covered Service Payment Obligation Waived

Cholesterol/lipid screenings, glucose screenings (without A1C), and venipuncture associated with labs when submitted with a preventive diagnosis when received from PPO or Participating Providers.

Deductible

Coinsurance

Copayment

Contraceptive medical devices, such as intrauterine devices and diaphragms received from PPO or Participating providers.

Deductible

Coinsurance

Copayment

Implanted and injected contraceptives received from PPO or

Participating providers.

Deductible

Coinsurance

Copayment

Medical evaluations and counseling for nicotine dependence per U.S.

Preventive Services Task Force (USPSTF) guidelines when received from PPO or Participating providers.

Deductible

Coinsurance

Copayment

Newborn’s initial hospitalization, when considered normal newborn care – facility and practitioner services.

Deductible

Coinsurance

Certain office visits and other services received from PPO Providers for the following conditions when receiving health support services from a

Wellmark Care Team nurse or support specialist:

◼ Asthma;

◼ Cardiovascular disease;

◼ Chronic kidney disease;

◼ Chronic pain; and

◼ Diabetes.

Deductible

Coinsurance

Copayment

One first trimester ultrasound and one second trimester ultrasound when the mother participates in the Pregnancy Care Program.

Deductible

Coinsurance

Copayment

Postpartum home visit (one).** Deductible

Form Number: Wellmark SD Grp/WYP_ 0125 11 PL001921 RL005302

Covered Service Payment Obligation Waived

Preventive care, items, and services,* received from PPO or

Participating providers, as follows:

◼ Items or services with an “A” or “B” rating in the current recommendations of the United States Preventive Services Task

Force (USPSTF);

◼ Immunizations as recommended by the Advisory Committee on

Immunization Practices of the Centers for Disease Control and

Prevention (ACIP);

◼ Preventive care and screenings for infants, children, and adolescents provided for in guidelines supported by the Health

Resources and Services Administration (HRSA); and

◼ Preventive care and screenings for women provided for in guidelines supported by the HRSA.

Deductible

Coinsurance

Copayment

Preventive digital breast tomosynthesis (3D mammogram) when received from PPO or Participating providers.

Deductible

Coinsurance

Copayment

Services subject to emergency room copayment amounts. Deductible

Services subject to office visit copayment amounts. Deductible

Coinsurance

Services subject to telehealth services copayment amounts.‡ Deductible

Coinsurance

Services subject to urgent care center copayment amounts. Deductible

Coinsurance

Vision examination (routine). Deductible

Coinsurance

Copayment

Voluntary sterilization for female members received from PPO or

Participating providers.

Deductible

Copayment

*A complete list of recommendations and guidelines related to preventive services can be found at www.healthcare.gov. Recommended preventive services are subject to change and are subject to medical management. USPSTF “A” and “B” recommendations will be implemented no later than the first plan year that begins on or after the date that is one year after the USPSTF recommendations are issued. A USPSTF recommendation is considered to be issued on the last day of the month on which it publishes or otherwise releases the recommendation. Waived Payment Obligations will be effective following implementation of the USPSTF recommendation.

**If you have a newborn child, but you do not add that child to your coverage, your newborn child may be added to your coverage solely for the purpose of administering benefits for the newborn during the first 48 hours following a http://www.healthcare.gov/

PL001921 RL005302 12 Form Number: Wellmark SD Grp/WYP_ 0125 vaginal delivery or 96 hours following a cesarean delivery. If that occurs, a separate deductible and coinsurance may be applied to your newborn child unless your coverage specifically waives the deductible or coinsurance for your newborn child.

‡Members can access telehealth services from Doctor on Demand through the Doctor on Demand mobile application or through myWellmark.com.

Prescription Drugs

Copayment Copayment is a fixed dollar amount you pay each time certain covered prescriptions subject to copayment are filled or refilled.

Coinsurance Coinsurance is the amount you pay, calculated using a fixed percentage of the maximum allowable fee, each time certain covered prescriptions subject to coinsurance are filled or refilled.

If you enroll in the PrudentRx program, for eligible specialty medications, you will have

$o out-of-pocket responsibility for prescriptions listed on the PrudentRx drug list.

You pay the entire cost if you purchase a drug or pharmacy durable medical equipment device that is not on the

Wellmark Blue Rx Value Plus Drug List. See

Wellmark Blue Rx Value Plus Drug List, page 39.

Out-of-Pocket Maximum The out-of-pocket maximum is the maximum you pay in a given benefit year toward the following amounts:

◼ Coinsurance.

◼ Copayments.

The family out-of-pocket maximum is reached from applicable amounts paid on behalf of any combination of covered family members.

A member will not be required to satisfy more than the single out-of-pocket maximum.

Out-of-pocket maximum amounts you pay for covered prescription drug benefits under

Blue Rx Value Plus also apply toward the

Blue Select medical out-of-pocket maximum. Likewise, out-of-pocket maximum amounts you pay for covered medical benefits under Blue Select apply toward the Blue Rx Value Plus out-of-pocket maximum.

If you do not enroll in the PrudentRx program, out-of-pocket maximum amounts you pay for drugs listed on the PrudentRx drug list that do not qualify as Essential

Health Benefits under the Affordable Care

Act will not count toward either your medical or prescription drug out-of-pocket maximum.

However, certain amounts do not apply toward your out-of-pocket maximum.

◼ Amounts representing any general exclusions and conditions. See General

Conditions of Coverage, Exclusions, and

Limitations, page 43.

◼ Difference in cost between the generic drug and the brand name drug when you purchase a brand name drug that has an FDA-approved “A”-rated medically appropriate generic equivalent.

These amounts continue even after you have met your out-of-pocket maximum.

PrudentRx Your employer or group sponsor has chosen to utilize PrudentRx for copayment assistance for specialty medications.

PrudentRx will assist you by helping you enroll in drug manufacturer copay assistance programs. If you are taking a medication listed on the PrudentRx drug list, PrudentRx will contact you directly to enroll. If you enroll with PrudentRx to get copayment assistance for your eligible specialty medication, you will have $0 out-http://mywellmark.com/

Form Number: Wellmark SD Grp/WYP_ 0125 13 PL001921 RL005302 of-pocket responsibility for prescriptions covered under the PrudentRx drug list. If you do not enroll in the PrudentRx program, by expressly refusing to enroll, or by not responding to PrudentRx’s attempts to contact you, you may be responsible for the full coinsurance related to specialty medications as listed in the Payment

Summary, but said coinsurance may not count toward your out-of-pocket maximum.

The PrudentRx drug list can be found at

Wellmark.com/member/prescription-drugs. For drugs listed on the PrudentRx drug list that do not qualify as Essential

Health Benefits under the Affordable Care

Act, your coinsurance will continue to apply even after you satisfy your out-of-pocket maximum.

Because certain specialty medications do not qualify as Essential Health Benefits under the Affordable Care Act, member cost share payments for these medications, whether made by you or PrudentRx, do not count towards the Plan’s out-of-pocket maximum and may not be subject to your

Plan’s out-of-pocket maximum. A list of specialty medications that are not considered to be Essential Health Benefits is available. An exception process is available for determining whether a medication that is not an Essential Health Benefit is medically necessary for a particular individual.

Waived Payment Obligations To understand your complete payment obligations you must become familiar with this entire summary plan description. Most information on coverage and benefits maximums will be found in the Details – Covered and Not Covered section.

Some payment obligations are waived for the following covered drugs or services.

Covered Drug or Service Payment Obligation Waived

Generic contraceptive drugs and generic contraceptive drug delivery devices (e.g., birth control patches).

Payment obligations are also waived if you purchase brand name contraceptive drugs or brand name drug delivery devices when an

FDA-approved medically appropriate generic equivalent is not available.

Payment obligations are not waived if you purchase brand name contraceptive drugs or brand name contraceptive drug delivery devices when an FDA-approved medically appropriate generic equivalent is available.

Copayment

Generic Medication Assisted Treatment agents for opioid use disorder. Copayment

Prenatal vitamins. Copayment

Prescription specialty medications listed on the PrudentRx drug list if you enroll with PrudentRx.

PL001921 RL005302 14 Form Number: Wellmark SD Grp/WYP_ 0125

Covered Drug or Service Payment Obligation Waived

Preventive items or services* as follows:

◼ Items or services with an “A” or “B” rating in the current recommendations of the United States Preventive Services Task

Force (USPSTF); and

◼ Immunizations as recommended by the Advisory Committee on

Immunization Practices of the Centers for Disease Control and

Prevention (ACIP).

Copayment

Two smoking cessation attempts per calendar year, up to a 90-days' supply of covered drugs for each attempt, or a 180-days' supply total per calendar year.

Copayment

*A complete list of recommendations and guidelines related to preventive services can be found at www.healthcare.gov. Recommended preventive items and services are subject to change and are subject to medical management. USPSTF “A” and “B” recommendations will be implemented no later than the first plan year that begins on or after the date that is one year after the USPSTF recommendations are issued. A USPSTF recommendation is considered to be issued on the last day of the month on which it publishes or otherwise releases the recommendation. Waived Payment Obligations will be effective following implementation of the USPSTF recommendation.

http://www.healthcare.gov/

Form Number: Wellmark SD Grp/AGC_ 0125 15 PL001921 RL005302

2. At a Glance - Covered and Not Covered

Medical

Your coverage provides benefits for many services and supplies. There are also services for which this coverage does not provide benefits. The following chart is provided for your convenience as a quick reference only. This chart is not intended to be and does not constitute a complete description of all coverage details and factors that determine whether a service is covered or not. All covered services are subject to the contract terms and conditions contained throughout this summary plan description. Many of these terms and conditions are contained in

Details – Covered and Not Covered, page 19. To fully understand which services are covered and which are not, you must become familiar with this entire summary plan description. Please call us if you are unsure whether a particular service is covered or not.

The headings in this chart provide the following information:

Category. Service categories are listed alphabetically and are repeated, with additional detailed information, in Details – Covered and Not Covered.

Covered. The listed category is generally covered, but some restrictions may apply.

Not Covered. The listed category is generally not covered.

See Page. This column lists the page number in Details – Covered and Not Covered where there is further information about the category.

Benefits Maximums. This column lists maximum benefit amounts that each member is eligible to receive. Benefits maximums that apply per benefit year or per lifetime are reached from benefits accumulated under this group health plan and any prior group health plans sponsored by your employer or group sponsor and administered by Wellmark Blue Cross and

Blue Shield of South Dakota.

Category C o ve re d

N o t C o ve

S ee

P ag e

Benefits Maximums

Acupuncture Treatment ⚫

12 visits per benefit year for acupuncture treatment.

Alcoholism Treatment ⚫ 19

Allergy Testing and Treatment ⚫ 19

Ambulance Services ⚫ 19

Anesthesia ⚫ 20

Applied Behavior Analysis (ABA) Services

Autism Spectrum Disorder Treatment ⚫ 21

Blood and Blood Administration ⚫ 21

Chemical Dependency Treatment ⚫ 21

Chemotherapy and Radiation Therapy ⚫ 22

At A Glance – Covered and Not Covered

PL001921 RL005302 16 Form Number: Wellmark SD Grp/AGC_ 0125 o ve t C o ve

P

Clinical Trials – Routine Care Associated with Clinical Trials

⚫ 22

Contraceptives ⚫

Conversion Therapy 22

Cosmetic Services 22

Counseling and Education Services ⚫

Dental Treatment for Accidental Injury ⚫ 23

Dialysis ⚫ 23

Education Services for Diabetes ⚫ 24

Emergency Services ⚫ 24

Fertility and Infertility Services ⚫ 24

Genetic Testing ⚫ 25

Hearing Services ⚫ 25

Home Health Services ⚫ 25

The daily benefit for short-term home skilled nursing services will not exceed Wellmark’s daily maximum allowable fee for skilled nursing facility services.

Home/Durable Medical Equipment ⚫ 26

Hospice Services ⚫ 26

15 days per lifetime for inpatient hospice respite care.

15 days per lifetime for outpatient hospice respite care.

Please note: Hospice respite care must be used in increments of not more than five days at a time.

Hospitals and Facilities ⚫ 27

Illness or Injury Services ⚫ 27

Inhalation Therapy ⚫ 28

Maternity Services ⚫ 28

Medical and Surgical Supplies and Personal Convenience Items

⚫ 28

Mental Health Services ⚫ 29

Motor Vehicles 30

Musculoskeletal Treatment ⚫ 30

Nonmedical or Administrative Services 30

Nutritional and Dietary Supplements ⚫ 31

Nutritional Counseling ⚫ 31

Occupational Therapy ⚫ 31

Orthotics (Foot) 31

Form Number: Wellmark SD Grp/AGC_ 0125 17 PL001921 RL005302 o ve t C o ve

P

Physical Therapy ⚫ 32

Physicians and Practitioners 32

Advanced Registered Nurse Practitioners

⚫ 32

Audiologists ⚫ 32

Certified Registered Nurse Anesthetists ⚫ 32

Chiropractors ⚫ 32

Dentists—but not for general dentistry ⚫ 32

Doctors of Osteopathy ⚫ 32

Licensed ABA Therapists ⚫ 32

Licensed Independent Social Workers ⚫ 32

Medical Doctors ⚫ 32

Nurse Practitioners and Midwives ⚫ 32

Occupational Therapists ⚫ 32

Optometrists ⚫ 32

Oral Surgeons ⚫ 32

Physical Therapists ⚫ 32

Physician Assistants ⚫ 32

Podiatrists ⚫ 32

Psychologists ⚫ 32

Qualified Mental Health Professionals ⚫ 32

Speech Pathologists ⚫ 33

Prescription Drugs ⚫ 33

Preventive Care ⚫ 34

Well-child care until the child reaches age seven.

One routine physical examination per benefit year.

One routine mammogram per benefit year.

One routine Pap smear per benefit year.

One diagnostic screening for prostate cancer per benefit year, including digital rectal examination and prostate-specific antigen (PSA) test, for:

◼ Asymptomatic men aged 50 and older;

◼ Men 45 and older who are at a high risk for prostate cancer.

Prosthetic Devices ⚫ 36

Reconstructive Surgery ⚫ 36

Self-Help Programs 36

Sleep Apnea Treatment ⚫ 36

Social Adjustment 36

Speech Therapy ⚫ 36

Surgery ⚫ 37

Telehealth Services ⚫

Temporomandibular Joint Disorder

(TMD)

⚫ 37

PL001921 RL005302 18 Form Number: Wellmark SD Grp/AGC_ 0125 o ve t C o ve

P

Transplants ⚫ 37

Travel or Lodging Costs ⚫ 38

Vision Services ⚫ 38

One routine vision examination per benefit year.

Wigs or Hairpieces 38

X-ray and Laboratory Services ⚫ 38

Prescription Drugs

Please note: To determine if a drug is covered, you must consult the Wellmark Blue Rx Value

Plus Drug List. You are covered for drugs listed on the Wellmark Blue Rx Value Plus Drug List.

If a drug is not on the Wellmark Blue Rx Value Plus Drug List, it is not covered unless it is a

Non-Formulary Drug and an exception has been approved by Wellmark for coverage. See

Exception Requests for Non-Formulary Prescription Drugs, page 93.

For details on drug coverage, drug limitations, and drug exclusions, see the next section, Details

– Covered and Not Covered.

Form Number: Wellmark SD Grp/DE_ 0125 19 PL001921 RL005302

3. Details - Covered and Not Covered

All covered services or supplies listed in this section are subject to the general contract provisions and limitations described in this summary plan description. Also see the section

General Conditions of Coverage, Exclusions, and Limitations, page 43. If a service or supply is not specifically listed, do not assume it is covered.

Medical

Acupuncture Treatment Covered: Acupuncture treatment.

Acupuncture is a treatment in which the skin is penetrated with needles in order to stimulate certain points on the body. This may or may not be accompanied by electrical stimulation.

Benefits Maximum:

◼ 12 visits per benefit year for acupuncture treatment.

Not Covered: Acupressure treatment.

See Also:

Physicians and Practitioners later in this section.

Alcoholism Treatment Covered.

Licensed Substance Abuse Treatment

Program. Benefits are available for alcoholism treatment in the following settings:

◼ Treatment provided in an office visit, or outpatient setting;

◼ Treatment provided in an intensive outpatient setting;

◼ Treatment provided in an outpatient partial hospitalization setting;

◼ Drug or alcohol rehabilitation therapy or counseling provided while participating in a clinically managed low intensity residential treatment setting, also known as supervised living;

◼ Treatment, including room and board, provided in a clinically managed medium or high intensity residential treatment setting;

◼ Treatment provided in a medically monitored intensive inpatient or detoxification setting; and

◼ For inpatient, medically managed acute care for patients whose condition requires the resources of an acute care general hospital or a medically managed inpatient treatment program.

Not Covered:

◼ Room and board provided while participating in a clinically managed low intensity residential treatment setting, also known as supervised living.

◼ Recreational activities or therapy, social activities, meals, excursions or other activities not considered clinical treatment, while participating in substance abuse treatment programs.

See Also:

Chemical Dependency Treatment later in this section.

Hospitals and Facilities later in this section.

Notification Requirements and Care

Coordination, page 59.

Allergy Testing and Treatment Covered.

Ambulance Services Covered:

◼ Emergency air and ground ambulance transportation to a hospital.

All of the following are required to qualify for benefits:

Details – Covered and Not Covered

PL001921 RL005302 20 Form Number: Wellmark SD Grp/DE_ 0125

⎯ If you are inpatient, the services required to treat your illness or injury are not available where you are currently receiving care.

⎯ You are transported to the nearest hospital with adequate facilities to treat your medical condition.

⎯ During transport, your medical condition requires the services that are provided only by an air or ground ambulance.

⎯ Your medical condition requires immediate ambulance transport.

⎯ In addition to the preceding requirements, for emergency air ambulance services to be covered, the following must be met:

◼ Great distances, inaccessibility of the pickup location by a land vehicle, or other obstacles are involved in getting you to the nearest hospital with appropriate facilities for treatment by ground transport.

When the No Surprises Act applies to air ambulance services, you cannot be billed for the difference between the amount charged and the total amount paid by us.

In an emergency situation, if you cannot reasonably utilize a PPO ambulance service, covered services will be reimbursed as though they were received from a PPO ambulance service.

However, if ground ambulance services are provided by an Out-of-Network

Provider, and because we do not have contracts with Out-of-Network

Providers and they may not accept our payment arrangements, you may be responsible for any difference between the amount charged and our amount paid for a covered service. When receiving non-emergency ground ambulance services, select a provider who participates in your network to avoid being responsible for any difference between the billed charge and our settlement amount.

◼ Non-emergency air or ground ambulance transportation to a hospital or nursing facility.

All of the following are required to qualify for benefits:

⎯ The services required to treat your illness or injury are not available where you are currently receiving care.

⎯ You are transported to the nearest hospital or nursing facility with adequate facilities to treat your medical condition.

⎯ During transport your medical condition requires the services that are provided only by an air or ground ambulance.

⎯ In addition to the preceding requirements, for non-emergency air ambulance services to be covered, all of the following must be met:

◼ You must already be receiving care at a hospital.

◼ Great distances, inaccessibility of the pickup location by a land vehicle, or other obstacles are involved in getting you to the nearest hospital or nursing facility with appropriate facilities for treatment by ground transport.

Not Covered:

◼ Air or ground ambulance transport from a facility capable of treating your condition.

◼ Air or ground ambulance transport to or from any location when you are physically and mentally capable of being a passenger in a private vehicle.

◼ Round-trip transports from your residence to a medical provider for an appointment or treatment and back to your residence.

◼ Air or ground transport when performed primarily for your convenience or the convenience of your family, physician, or other health care provider, such as a

Form Number: Wellmark SD Grp/DE_ 0125 21 PL001921 RL005302 transfer to a hospital or facility that is closer to your home or family.

◼ Non-ambulance transport to any location for any reason. This includes private vehicle transport, commercial air transport, police transport, taxi, public transportation such as train or bus, ride-share vehicles such as Uber or Lyft, and vehicles such as vans or taxis that are equipped to transport stretchers or wheelchairs but are not professionally operated or staffed.

Anesthesia Covered: Anesthesia and the administration of anesthesia.

Not Covered: Local or topical…