Exhibit B.pdf

2 0 2 4 - 2 0 2 5 E M P L O Y E E

Benefits Guide & R E F E R E N C E M A N U A L

DISCOVER NEW

BENEFITS

Hinge Health

Wellness Champions Are Going Statewide

OPEN ENROLLMENT IS

May 1–15, 2024

YOU MUST PARTAKE

IN THIS YEAR'S

Active Enrollment

CHANGES TO THE

LiveWellSD Rewards

Get Connected

Having access to your benefits and well-being information is essential in today's world. That's why we have partnered with vendors that make it easier than ever for you to access information and resources.

�Wellness At Your Side: Take hold of your personal well-being goals. The Wellness at Your Side app allows you to log in to your LiveWellSD/WebMD portal at any time.

Participate in challenges, review resources, and more.

�myWellmark: Enjoy instant access to your health care information with the myWellmark app. See what services and medications are covered, estimate costs, track your deductibles, access your mobile health ID card, and more.

�myStrength: Strengthen your emotional health wherever and whenever you need to with the myStrength app.

Receive customized support and tools for stress, depression, sleep, and more. Use this app to feel more relaxed, inspired, and hopeful. A new app is coming soon.

To learn more about the EAP program, wisit https://bhr.

sd.gov/benefits/eap/.

�GuidanceNow: This app from GuidanceResources provides you with fast and easy access not only to your Employee Assistance Program, but a wide range of health and well-being tools. Access program information, find providers, and browse written and video resources.

�Doctor on Demand: Use this app to connect face to face with a doctor, psychologist, or psychiatrist through your mobile device 24 hours a day, 7 days a week.

�EyeMed: Vision plan information at your fingertips. View your benefits and eligibility, find in-network providers, check on the status of a claim, set reminders, or get your ID card with a quick (and literal) shake of your hand.

Delta Dental: Access your dental plan information anyplace, anytime. The Delta Dental Mobile App lets you find providers, save your preferred dentist, and estimate costs. You can also call up your mobile ID card at the touch of a button.

FOLLOW BENEFITS ON SOCIAL MEDIA

facebook.com/sdbenefits instagram.com/sdbenefits x.com/benefitssd

All apps are available on both iOS and Android devices.

Use WebID code southdakota for the myStrength and Wellness At Your Side apps.

Use your Wellmark ID for the myWellmark app.

COMPLIANCE

This guide contains basic information to help members of the South Dakota State Employee Benefits Program prepare for FY25 Open Enrollment. Complete plan information can be found at bhr.sd.gov/benefits. The health plan summary plan description (SPD) or the insurance carrier’s plan certificates should be consulted for coverage, benefits information, exclusions, and other important information. The benefit information provided in this guide is not all inclusive. If there is a discrepancy between the benefits guide and the SPD or plan certificates, the SPD or plan certificates prevail.

Additional compliance documents are available at https://bhr.sd.gov/benefits/forms-documents/compliance/

WELLMARK

YOUR HEALTH PLAN OPTIONS

DENTAL PLANS

THE LIVEWELLSD

PROGRAM

HOW TO ENROLL

What’s Inside What’s New?

Frequently Used Terms Dependent Verification/Opting Out The ALEX Tool Welcome to Wellmark Washington Plan Lincoln Plan Jefferson Plan Roosevelt Plan Pharmacy Benefits Compare the Plans Options for Affordable Care The LiveWellSD Program The Wellmark Care Team Dental Plans Vision Plan Health Savings Account Flexible Spending Accounts Health Reimbursement Account Combination FSAs/HRAs Critical Illness Basic Life Insurance Supplemental Life/AD&D and Long-Term Care Short-Term Disability Plan Accident Insurance Plan Hospital Indemnity Plan Employee Assistance Program How to Enroll Contacts

18 20

What’s New for FY25?

Hinge Health

The State of South Dakota is proud to partner with Hinge Health, a digital clinic for joint and muscle pain.

Combining expert clinical care and advanced technology, this service will provide employees and covered family members to move beyond pain and injury, avoid unnecessary surgeries when possible, and reduce opioid use.

The digital clinic will help you whether you are at-risk and worried about prevention, have suffered an acute injury, are suffering from chronic pain, or recovering from surgery. Hinge Health uses comprehensive and tailored programs in the palm of your hand with the official app. Additional details are available on https://bhr.sd.gov/benefits/health-plans/hinge/

Change in Well-Being Rewards We are implementing adjustments to the Well-Being Rewards program for the new fiscal year. Starting in FY25, an employee will no longer be required to participate in well-being activities to earn rewards. Instead, the primary policyholder and their covered spouse will need to complete the online Health Assessment and Annual Wellness Exam to earn reward dollars.

To earn reward dollars, the primary policyholder (and their covered spouse) must complete both the Health Assessment and the Annual Wellness Exam, including blood work. Incentive dollars earned between April 2, 2024, and April 1, 2025, will be awarded in FY26. These rewards will be deposited into either an HSA or HRA, depending on the employee's coverage level in FY25 and the health plan they are enrolled in as of July 1, 2025.

Employee – $500 Employee plus Spouse – $750 Employee plus Child(ren) – $750 Employee plus Family – $1,000

For more information on the LiveWellSD Program, see page 18.

Wellness Champions We are expanding the Wellness Champion network statewide! This comes after a successful pilot program with several agencies and universities.

The Wellness Champion network is a partnership between agencies with a focus on the health and safety of our employees. This partnership between agencies will bring awareness and give employees an opportunity to take an active role in the total well-being of our employees. Watch for more to come as we begin the statewide rollout of this network.

Employee Health Office The Employee Health Office focuses on safety first with attention to the well-being of employees and their families by providing solutions to everyday life situations. Additional information will soon be available online.

Back to Table of Contents https://bhr.sd.gov/benefits/health-plans/hinge/

IMPORTANT!

FY25 Open Enrollment will be an Active Enrollment, which means that you must log in to Employee Space between May 1–May 15, 2024 to elect your benefits for the plan year beginning July 1, 2024.

If you do not log in and participate, you will be enrolled in the Washington High Deductible Health plan with employee-only coverage. Any flexible benefits coverage you currently enjoy will be discontinued. Covered dependents will also lose coverage.

Please note that if you are married to a State employee and you choose to cover your spouse on the health plan, your spouse will need to opt-out of the health plan.

Employees cannot be dually covered under the health plan.

This is true for dependents as well. If your eligible dependent children are covered under your health plan, and are State employees, they cannot be dually covered under the health plan.

More benefit updates

HEALTH

�The State offers a plan with no premium for employee-only coverage: the Washington Plan. The Lincoln, Jefferson, and Roosevelt Plans are offered so you can buy up coverage that best fits you and your family's needs.

�Employees may enroll in any of the four health plans they wish.

�Married State employees are not required to carry separate health care plans; they can be on the same health plan.

Additionally, eligible dependent children who are covered on a parent’s plan and who then become employed by the State are not required to carry a separate health plan. This means dependent children can stay on the parent’s plan as long as they continue to meet the eligibility requirements.

�On all health plans, employees will receive one eye exam per year for each covered member of their family. This is in addition to the exam that's included if you elect vision insurance.

�Those who choose to opt out of the health plan will not be able to elect a full medical FSA. However, you can elect a combination FSA. Learn more on page 26.

PHARMACY

�Along with health insurance, Wellmark Blue Cross and Blue Shield administers the State's pharmacy benefits in partnership with CVS. That means you can access national networks and comprehensive coverage, along with the tools, resources, specialty pharmacy and savings opportunites that come with being a Wellmark member.

For the 2024-2025 plan year, the State is introducing a new pharmacy benefit called Prudent RX for plan members enrolled in the Jefferson and Roosevelt plans who utilize specialty prescriptions. Learn more on pages 14-15.

WELL-BEING REWARDS

�If you completed well-being qualifications during the 2023-24 program year, you may be eligible for reward dollars. Eligible employees who enroll in one of the high-deductible health plans will receive a contribution into an HSA, while those who enroll in one of the low deductible health plans will receive a contribution applied to an HRA.

You must have been the primary policyholder during FY24 while earning the reward and must enroll as the primary policyholder for next year.

Visit bhr.sd.gov/livewellsd/ to check your rewards earned, which will be added to WEX accounts by August 2024.

Frequently Used Terms The language of health insurance can be confusing. Keep this list of common terms handy as you explore your open enrollment materials; it will help you understand and choose the plan that’s right for you. For more terms and definitions, visit https://bhr.sd.gov/fy25plans/.

�Coinsurance: The percentage you pay for care or prescriptions after you’ve reached your deductible. Your plan pays the remaining percentage until you reach your out-of-pocket maximum, or OPM. Then your plan takes over and pays 100% of your costs for the rest of the plan year.

�Copayment/copay: A fixed dollar amount you pay for care or prescriptions, usually at the time of service.

�Deductible: The amount of money you pay out of pocket for care and prescriptions before your plan begins to pay benefits.

���Dependent: An eligible spouse or child you elect to cover on your health plan or flexible benefits.

��Eligible employee: A permanent full-time employee, permanent part-time employee, or an employee of a participating unit who has worked an average of 30 hours or more per week during a 12-month period, as defined by the Patient Protection and Affordable Care Act of 2010.

��Health reimbursement account (HRA): An employer-funded account that members can use to be reimbursed for certain medical, pharmacy, dental, and vision expenses. See page 26.

��Health savings account (HSA): For those who elect a high-deductible health plan, a triple tax-advantaged account that lets you and your employer set aside funds for eligible healthcare costs. See page 24.

�In-network: Healthcare providers who have agreed to accept discounted rates for products and services from the insurance plan. You will pay much less at in-network doctors, hospitals, and pharmacies.

��Network: The doctors, hospitals, pharmacies, and other providers and suppliers your health plan contracts with to provide care and services.

Out-of-network: Out-of-network healthcare providers have not contracted with our insurance company to accept discounted rates. You will pay much less at in-network doctors, hospitals, and pharmacies.

�Out-of-pocket maximum: The most you have to pay out of pocket in a plan year. After you spend this amount on deductibles, copays, and coinsurance, the plan pays 100% of your covered medical and prescription costs.

�Preauthorization: A decision by your health plan that a service, treatment plan, prescription drug, or durable medical equipment is medically necessary.

Preauthorization is sometimes required before care will be covered. It can also be called prior authorization, prior approval, or precertification.

��Preventive care/services: Care received to prevent disease rather than treat it. Examples include routine screenings, well-child care, and immunizations.

Embedded deductibles bring you more value and make your deductible easier to manage. The Washington, Lincoln, and Jefferson Plans all have embedded deductibles. (The Roosevelt Plan does not have a deductible to meet) Let’s look at how an embedded deductible works with the Washington Plan:

Kelly is single and has two children, Jason and Mandy.

Kelly experiences acute appendicitis, resulting in an emergency room visit, an overnight stay in the hospital, and surgery that adds up to $7,500.

With this payment, Kelly has met her individual embedded deductible — she pays $5,750, and the plan pays the remaining $1,750, along with the rest of her covered medical and prescription costs for the plan year.

The remaining unmet family deductible is $5,750. Jason incurs $1,000 in doctor visits, and Mandy incurs another $4,750 in emergency room visits and prescription costs.

The family has met the remaining $5,750 of the $11,500 family deductible and OPM, and the entire family’s eligible healthcare and prescription expenses are covered at 100% for the rest of the plan year.

Learn more at bhr.sd.gov/fy25plans/.

Qualifying Life Events and Dependent Verification Requirements If you request to add a spouse or dependent(s) to your health or flexible benefits during open enrollment or because of a qualifying event — and they were not previously covered under your benefits — you must submit acceptable proof of dependent eligibility to the State of South Dakota Benefits Program.

�If you experience a qualifying event and wish to update your benefits, you must complete and submit a Life Event Change request through Employee Space, within 30 days of the event date.

You may also be required to submit acceptable proof of dependent eligibility and supporting documentation that a qualifying life event has occurred. For more information on Qualifying Life Events, visit https://bhr.sd.gov/benefits/lifeevents/

��Newly hired employees are required to submit dependent eligibility verification within 30 days of their hire date.

��If you fail to submit the required proof of dependent eligibility and/ or supporting documentation within the 30-day window, your spouse and/or dependent(s) will not be enrolled and your change request will be denied. If this occurs, your next opportunity to make changes to your benefits is during the next open enrollment period or if you experience another qualfying life event.

�If your dependent child is over the age of 26 and either a full-time student or a qualified disabled dependent child, you may be required to provide supporting documentation to verify continuing eligibility.

Failure to provide documentation will result in your dependent being removed from coverage, and you will not be able to re-enroll that dependent for benefit coverage.

Opting Out

You can opt out of the South Dakota State Employee Health Plan if you provide proof of other creditable group health coverage.

��If you currently opt out, you must participate in open enrollment this year or you will be enrolled in the Washington Plan with employee-only coverage. Any flexible benefits coverage you currently enjoy will be discontinued. Covered dependents will also lose coverage.

�Acceptable proof of coverage includes:

• �A Certificate of Creditable Coverage from your other insurance carrier.

• �A TRICARE identification card showing continued coverage.

• �A Medicare identification card showing continued coverage.

Please note: Other creditable coverage does not include Medicaid, Indian Health Services, or coverage obtained through the Marketplace Exchange.

The deadline to submit your proof of creditable coverage is May 22, 2024. Email it to benefitswebsite@state.sd.us.

Picking the right health plan can be challenging. How do you know which one is right for you? To answer your questions and simplify the process, State employees can access an easy-to-use online tool called ALEX.

Just log on and respond to ALEX’s questions. ALEX will … �Prompt you for some basic information.

�Ask a few questions about how you and your family use health benefits.

�Help you figure out which plan to choose during open enrollment based on your responses.

With simple language that avoids insurance jargon, talking with ALEX feels like having a conversation with a real person. And, ALEX is available anywhere that’s convenient for you. Log on from your work computer, your smart phone, or your home computer with an internet connection.

Learn more at https://start.myalex.com/benefitssd/

NOTE: ALEX does NOT enroll you in benefits.

ALEX makes suggestions based on your answers so that, during open enrollment, you can make the decision that feels right for you. To successfully enroll, you must log in and elect benefits. See instructions for logging in on page 34.

8 Back to Table of Contents

STRONGER COVERAGE, BETTER BENEFITS

Wellmark Members enjoy:

• Network discounts.

• �Coverage at 95% of physicians and 100% of hospitals in South Dakota.

• �Access to the nationwide Blue Cross and Blue Shield network.

• Care Management to help navigate health conditions.

You have access to free tools and resources, including:

• �myWellmark®, your secure member portal for access to all your health benefits information at home or on the go.

• �Livongo® Diabetes Management, a free program for management of type 1 and type 2 diabetes.

• �Livongo Diabetes Prevention, a free program for prevention of type 1 and type 2 diabetes.

• �Wellmark’s Blue365® program for discounts and deals on healthy purchases.

• �BeWell 24/7®, a free phone line to answer your health questions and help you navigate the healthcare system 24/7.

• �IDX Identity® for identity theft protection.

• Pregnancy Care Management, a free program to support expectant mothers.

For more information, please visit the Health and Pharmacy Guide: bhr.sd.gov/benefits/ HealthPharmacyGuide.pdf

Wellmark We are pleased to continue our partnership with Wellmark® to deliver our health benefits. While our plan is self-insured — meaning the State assumes all financial responsibility — we need a partner to administer claims payments and negotiate network discounts. That partner is Wellmark Blue Cross® and Blue Shield® of South Dakota.

Based in Sioux Falls, Wellmark of South Dakota offers the largest health care provider network in the state. Approximately 386,000 South Dakotans have healthcare coverage through Wellmark, and they’re in good company: One in every three Americans is covered by a Blue Cross and Blue Shield plan.

As a Wellmark member, you’ll enjoy access to a broad range of doctors, hospitals, and telehealth benefits.

To learn more about our health insurance administrator, visit Wellmark.com.

Not all employees will get new ID cards at open enrollment.

Only members who change plans, enroll for the first time, or go from single to family coverage at open enrollment will receive new ID cards.

https://bhr.sd.gov/benefits/healthpharmacyguide.pdf

The Washington Plan

H I G H - D E D U C T I B L E H E A LT H P L A N

PREMIUMS 24 PAY

PERIODS

12 PAY

PERIODS

Employee $0 $0

Employee + spouse $54.46 $108.92

Employee + child(ren) $22.61 $45.22

Family $65.97 $131.94

Administered by Wellmark Blue Cross and Blue Shield

YOUR COST SHARE

Deductible Medical $5,750 single

$11,500 family

Pharmacy Combined with medical deductible

Coinsurance No coinsurance

Out-of-pocket max (OPM)

Medical & pharmacy combined

$5,750 single $11,500 family

Medical care

Office visits

Deductible

Urgent care

ER

Diagnostic tests (X-ray, blood work)

Outpatient

Inpatient

The Washington Plan is a true high-deductible health plan. It has no medical coinsurance or copays, and the deductible is the same amount as the out-of-pocket maximum (OPM). Once you reach your deductible, the plan will pay 100% of your costs for covered healthcare and prescriptions for the remainder of the plan year.

Here are some additional important things to know about the Washington Plan:

�This plan offers a $0 premium for employee-only coverage.

�Preventive services are 100% covered. Certain preventive prescriptions are also 100% covered.

�For those with family coverage, the plan includes an embedded deductible. If a family member meets $5,750 of their deductible

— half of the family deductible — the plan will then begin to pay 100% of their covered healthcare and prescription costs for the remainder of that plan year. Then, if a different family member (or combination of family members) reaches the additional $5,750 remaining deductible of $11,500, the plan will pay 100% of covered healthcare and prescription costs for all covered family members for the remainder of the plan year.

��This plan qualifies eligible employees for a Health Savings Account (HSA). Primary policyholders who complete well-being qualifications may receive reward dollar contribution towards their Health Savings Account. See page 24 for details.

See page 14 for pharmacy information.

�Covered services that are not considered preventive are still provided at discounted rates when an in-network provider is utilized.

The Lincoln Plan

H I G H - D E D U C T I B L E H E A LT H P L A N

PREMIUMS 24 PAY

PERIODS

12 PAY

PERIODS

Employee $13.76 $27.52

Employee + spouse $85.27 $170.54

Employee + child(ren) $43.40 $86.80

Family $103.32 $206.64

See page 14 for pharmacy information.

YOUR COST SHARE

Deductible Medical $3,500 single

$7,000 family

Pharmacy Combined with medical deductible

Coinsurance 25%

Out-of-pocket max (OPM)

Medical & pharmacy combined

$6,500 single $13,000 family

Medical care

Office visits

Deductible then coinsurance

Urgent care

ER

Diagnostic tests (X-ray, blood work)

Outpatient

Inpatient

The Lincoln Plan is another high-deductible health plan with affordable premiums. But unlike the Washington Plan, it includes coinsurance to allow for a more moderate deductible. Once you reach your deductible, the plan pays 75% of your costs for covered care and prescriptions, and you pay the remaining 25%. Once you reach your out-of-pocket maximum (OPM), the plan pays 100% of your covered costs. Here are some more important things to know about the Lincoln Plan:

�Preventive services are 100% covered. Certain preventive prescriptions are also 100% covered.

�For those with family coverage, the plan includes an embedded deductible. If a family member meets $3,500 of their deductible

— half of the family deductible — the plan will then begin to pay 75% of covered charges for that family member.

�This plan qualifies eligible employees for a Health Savings Account (HSA). Primary policyholders who complete well-being qualifications may receive reward dollar contribution towards their Health Savings Account. See page 24 for details.

“If I am paying 100% for care with an High Deductible Health Plan (HDHP), why should I even have insurance?”

Our insurance administrator negotiates discounts with doctors and hospitals on behalf of the State. Even though you pay for your healthcare costs up to your deductible, you still get those discounts — meaning you pay considerably less than if you weren’t covered by the plan at all.

Administered by Wellmark Blue Cross and Blue Shield

�Covered services that are not considered preventive are still provided at discounted rates when an in-network provider is utilized.

The Jefferson Plan

L O W - D E D U C T I B L E H E A LT H P L A N

The Jefferson Plan is a low-deductible health plan that includes a mix of copays and coinsurance. That means you’ll pay more in premiums than on an HDHP, but have more predictable out-of-pocket costs.

This plan may be a good option if you prefer the peace of mind of knowing you don’t have to save up for large or surprise healthcare expenses. Here are some more details about the Jefferson Plan:

�Preventive services are 100% covered.

�Office visits with primary care providers and specialists have a flat copay. Primary care refers to any non-specialty provider, including your primary care provider, OB/GYNs, physician's assistants, and nurse practitioners. Non-primary care refers to specialists, like dermatologists, oncologists, and cardiologists.

�All copays and coinsurance costs count towards your out-of-pocket maximum (OPM). Copays do not count towards your deductible. Once you meet your OPM, all covered care and prescriptions will be 100% paid for by the plan.

�For those with family coverage, the plan includes an embedded deductible. If a family member meets $1,750 of their deductible — half of the family deductible — the plan will then begin to pay 70% of covered charges for that family member.

�Like all low-deductible health plans, the Jefferson Plan does not qualify you for a health savings account (HSA). However, you can elect a medical flexible spending account (FSA) to set aside pre-tax money to pay for medical, prescription, dental, and vision care expenses. Primary policyholders who complete well-being qualifications may receive reward dollar contribution towards their Health Reimbursement Account (HRA) to offset costs during the plan year. See page 26 for details.

PREMIUMS 24 PAY

PERIODS

12 PAY

PERIODS

Employee $51.86 $103.72

Employee + spouse $167.61 $335.22

Employee + child(ren) $99.54 $199.08

Family $205.06 $410.12

YOUR COST SHARE

Deductible Medical $1,750 single

$3,500 family

Pharmacy No deductible

Coinsurance 30%

Out-of-pocket max (OPM)

Medical & pharmacy combined

$4,500 single $9,000 family

Medical care

Office visits $50 primary care $100 non-primary care

Urgent care $50

ER $250 +

30% coinsurance

Diagnostic tests (X-ray, blood work) Deductible then coinsuranceOutpatient

Inpatient

Administered by Wellmark Blue Cross and Blue Shield

See page 14 for pharmacy information.

The Roosevelt Plan is robust and uniquely easy to use. It has no deductible and no coinsurance; you only pay copays up to your out-of-pocket maximum. Because you will always know your costs for care and prescriptions, the plan makes it easy to maintain a budget and keep track of spending. Here is additional information about the Roosevelt Plan:

�Preventive services are 100% covered.

�The copay for office visits can vary depending on whether you receive primary care or non-primary care. Primary care refers to any non-specialty provider, including your primary care provider, OB/GYNs, physician's assistants, and nurse practitioners. Non-primary care refers to specialists, like dermatologists, oncologists, and cardiologists.

�All copays count towards your out-of-pocket maximum (OPM).

Once you meet your OPM, all covered care and prescriptions will be 100% paid for by the plan.

�Like all low-deductible health plans, the Roosevelt Plan does not qualify you for a health savings account (HSA). However, you can elect a medical flexible spending account (FSA) to set aside pre-tax money to pay for medical, prescription, dental, and vision care expenses. Primary policyholders who complete well-being qualifications may receive reward dollar contribution towards their Health Reimbursement Account (HRA) to offset costs during the plan year. See page 26 for details.

The Roosevelt Plan

L O W - D E D U C T I B L E H E A LT H P L A N

PREMIUMS 24 PAY

PERIODS

12 PAY

PERIODS

Employee $67.20 $134.40

Employee + spouse $201.80 $403.60

Employee + child(ren) $122.57 $245.14

Family $246.96 $493.92

YOUR COST SHARE

Deductible Medical No deductible

Pharmacy No deductible

Coinsurance No coinsurance

Out-of-pocket max (OPM)

Medical & pharmacy combined

$5,000 single $10,000 family

Medical care

Office visits $30 primary care $60 non-primary care

Urgent care $30

ER $500

Diagnostic tests (X-ray, blood work)

$30 in an office setting

Outpatient $2,500

Inpatient $3,500

Administered by Wellmark Blue Cross and Blue Shield

See page 14 for pharmacy information.

Along with our health plans, Wellmark is administering the State’s pharmacy benefits. That means you get comprehensive prescription drug coverage. And, it means all your medical and pharmacy benefits are in one place, making it easier for you to access resources that help you use your benefits and save money.

Note: You do not need to elect a pharmacy plan, as it is included with your health coverage. There is no additional premium or deductible.

Pharmacy Benefits

Administered by Wellmark Blue Cross and Blue Shield

Washington Plan Lincoln Plan Jefferson Plan Roosevelt Plan

Deductible Combined with medical deductible

Combined with medical deductible No deductible No deductible

Coinsurance No coinsurance 25% 30% No coinsurance

Out-of-pocket max (OPM) Medical & pharmacy combined

$5,750 single $11,500 family

$6,500 single $13,000 family

$4,500 single $9,000 family

$5,000 single $10,000 family

Prescription drugs

Tier 1 Deductible Deductible then 25% coinsurance $15 (30-day supply)

$37.50 (90-day supply) $25 (30-day supply)

$62.50 (90-day supply)Tier 1 preventive $0 $0

Tier 2 Deductible Deductible then 25% coinsurance $55 (30-day supply)

$137.50 (90-day supply) $65 (30-day supply)

$162.50 (90-day supply)Tier 2 preventive $55 (30-day supply)

$137.50 (90-day supply) $55 (30-day supply)

$137.50 (90-day supply)

Tier 3 Deductible Deductible then 37.5% coinsurance $75 (30-day supply)

$187.50 (90-day supply) $150 (30-day supply) $375 (90-day supply)Tier 3 preventive

$75 (30-day supply) $187.50 (90-day supply)

$75 (30-day supply) $187.50 (90-day supply)

Preferred specialty

Preventive list: $85 All other drugs: Deductible

Preventive list: $85 All other drugs: Deductible then coinsurance

$85 (Managed by Prudent RX)

$300 (Managed by Prudent RX)

Non-preferred specialty

Preventive list: $110 All other drugs: Deductible

Preventive list: $110 All other drugs: Deductible then coinsurance $110 $450

THE BLUE RX VALUE PLUSSM FORMULARY

Your plan is called Blue Rx Value Plus, and it’s based around a formulary: a list of covered drugs. The formulary helps guide you, your doctor and your pharmacist to the lowest cost drug options that effectively treat your condition. Understanding the formulary could help you save money.

PRESCRIPTION DRUG TIERS

Your plan has three levels of coverage called “tiers.” Your drug’s tier determines how much you’ll pay at the pharmacy. The lower the tier, the more affordable your prescription. If you choose to take a drug that’s not covered, you will pay the full cost for the medication.

USE YOUR FORMULARY TO SAVE

Follow these steps to use your formulary to research more affordable treatment options.

1. When you get a new prescription, go to Wellmark.com.

2. �Scroll down to the bottom of the page and select Prescription Drug Information and then Drug List. Then, scroll down and choose Blue Rx Value Plus from the Formulary Drug Lists.

3. �Finally, search for your drug by name.

• If your drug is considered preventive, it will be listed as PV.

• �If your drug is on a higher tier, you can ask your doctor if a lower-cost equivalent is appropriate.

• �If your drug is listed as non-formulary or NF, your drug is not covered. Ask your doctor for a medication that is covered by your plan.

SPECIALTY DRUGS

Medications that treat complex and chronic conditions - are also covered by your plan. Beginning July 1, 2024, you and your covered family members will be offered the opportunity to participate in a new program called PrudentRX.

Prudent RX offers a copay card on specialty medications, with your costs for these being as low as $0 until the copay card dollar amount expires. All covered members will be contacted if eligible for this program.

Please note: This program is available to members enrolled in the Jefferson and Roosevelt low deductible health plans.

PRESCRIPTION DRUG TIERS

CVS CAREMARK MEMBER PORTAL & APP

With the CVS Caremark member portal and app, you can access savings and manage pharmacy benefits anytime, anywhere.

• �Know your coverage and costs:

See if a medication is covered, find lowest-cost drug alternatives, and more.

• �Fill or refill prescriptions: Use the app to take a photo of the front and back of your new paper prescription, or scan the barcode on your existing Rx label to place a refill order.

• �Find a pharmacy: Locate in-network retail pharmacies near you.

• �Manage your profile: Set your notifications, update shipping and billing, and more.

Register and link to the free mobile app at Caremark.com/mobile.

TIER 1:

Most affordable drugs Includes most generics and select branded drugs.

TIER 2:

Preferred drugs Drugs that have been proven to be effective and favorably priced compared to other drugs that treat the same condition

TIER 3:

Non-preferred drugs Drugs that are not as cost-effective as available generics or preferred brands.

Low out-of-pocket costs

Middle-value out-of-pocket costs

Higher out-of-pocket costs

YOUR IN-NETWORK COST SHARE

Deductible Medical

$5,750 single $11,500 family

$3,500 single $7,000 family

$1,750 single $3,500 family

No deductible

Pharmacy Combined with medical deductible

Combined with medical deductible No deductible No deductible

Coinsurance No coinsurance 25% 30% No coinsurance

Out-of-pocket max (OPM)

Medical & pharmacy combined

$5,750 single $11,500 family

$6,500 single $13,000 family

$4,500 single $9,000 family

$5,000 single $10,000 family

Medical care

Office visits

Deductible Deductible then coinsurance

$50 primary care $100 non-primary care

$30 primary care $60 non-primary care

Urgent care $50 $30

ER $250 + 30% coinsurance $500

Diagnostic tests (X-ray, blood work)

Deductible then coinsurance

$30 in an office setting

Outpatient $2,500

Inpatient $3,500

Prescription drugs

Tier 1 Deductible Deductible then 25% coinsurance $15 (30-day supply)

$37.50 (90-day supply) $25 (30-day supply)

$62.50 (90-day supply)Tier 1 preventive $0 $0

Tier 2 Deductible Deductible then 25% coinsurance $55 (30-day supply)

$137.50 (90-day supply) $65 (30-day supply)

$162.50 (90-day supply)Tier 2 preventive $55 (30-day supply)

$137.50 (90-day supply) $55 (30-day supply)

$137.50 (90-day supply)

Tier 3 Deductible Deductible then 37.5% coinsurance $75 (30-day supply)

$187.50 (90-day supply) $150 (30-day supply) $375 (90-day supply)Tier 3 preventive

$75 (30-day supply) $187.50 (90-day supply)

$75 (30-day supply) $187.50 (90-day supply)

Preferred specialty

Preventive list: $85 All other drugs: Deductible

Preventive list: $85 All other drugs: Deductible then coinsurance

$85 (Managed by Prudent RX)

$300 (Managed by Prudent RX)

Non-preferred specialty

Preventive list: $110 All other drugs: Deductible

Preventive list: $110 All other drugs: Deductible then coinsurance $110 $450

Washington Plan Lincoln Plan Jefferson Plan Roosevelt Plan 24 PAY PERIODS 12 PAY PERIODS 24 PAY PERIODS 12 PAY PERIODS 24 PAY PERIODS 12 PAY PERIODS 24 PAY PERIODS 12 PAY PERIODS

Employee* $0 $0 $13.76 $27.52 $51.86 $103.72 $67.20 $134.40

Employee + spouse* $54.46 $108.92 $85.27 $170.54 $167.61 $335.22 $201.80 $403.60

Employee + child(ren)* $22.61 $45.22 $43.40 $86.80 $99.54 $199.08 $122.57 $245.14

Family* $65.97 $131.94 $103.32 $206.64 $205.06 $410.12 $246.96 $493.92

Compare Your Health Plan Options

*Tobacco surcharge: If you and/or your spouse use tobacco products, a surcharge will be added to your premiums. If you receive your paychecks in 24 pay periods, $30 will be added per person per pay period. If you receive your paychecks in 12 pay periods, $60 will be added per person per pay period.

For more information including out-of-network costs, see your plan summary documents on the BHR website.

Preventive care The earlier a serious medical condition is caught, the easier it is to treat. Preventing disease before it starts keeps your healthcare costs down and helps you live a longer, healthier life.

All State health plans pay 100% of preventive care costs for you and your covered spouse and dependents.

Based on your age and health status, this could include:

��An annual wellness exam ��A well-child exam ��A well-woman exam ��Cancer screenings ��Pregnancy care preventive screenings ��Scheduled vaccinations ��Tests and screenings for cholesterol and blood pressure levels, depression, and type 2 diabetes

Healthy living includes regular checkups with your health care provider to measure your most important health numbers, including your blood pressure, your cholesterol levels, and your body mass index. It is important to know your numbers and identify health risks early on when there’s time to help reduce or eliminate them.

To learn more about preventive care, please visit https://bhr.sd.gov/benefits/health-plans/preventive/ for a wide array of information.

Doctor On Demand®

With Doctor On Demand, you can have video visits with board-certified physicians and get treatment and prescriptions for a cold, flu, allergies, bugs your kids pick up, and more. It’s fast care anywhere — 24/7.*

And, Doctor On Demand offers mental health care, too.

Schedule talk therapy and medication management for stress, depression, anxiety, postpartum concerns, and more.

WHY SEE A DOCTOR ONLINE?

��Affordable: The app will provide you with an exact cost before you book your appointment.

• �Medical visits cost $30-$60 on all plans.

• �Mental health visits cost $30-$60 on traditional plans. On high-deductible plans, costs vary by length.

��Convenient: Available at home or on the go.

Fast: Be seen in minutes.

��Always there: Available 24/7, even in the middle of the night.

TO GET THIS BENEFIT

Coverage is included when you enroll in a State health plan. Visit DoctorOnDemand.com to register, and then go to the App Store® or Google Play® to download the app for free.

*Doctor On Demand physicians do not prescribe Scheduled I-IV DEA Controlled Substances and may elect not to treat or prescribe other medications based on what is clinically appropriate. During times of high overnight call volume, patients may be directed to make an appointment with a Doctor On Demand physician for the following morning.

Options for Affordable Care

Your Well-Being is Our Priority LiveWellSD emphasizes our commitment to empowering employees and their families to take charge of their total well-being to live their best life at work and at home. Whether you want to be more physically fit, socially connected, emotionally balanced, or financially secure, we have resources to support you on your well-being journey.

The LiveWellSD Portal: Your One Stop for Total Well-Being Powered by WebMD, the portal creates a custom experience to support your personal goals and interests. Programs and resources are always available by logging in with your username and password at bhr.sd.gov/livewellsd. If you have not yet created an account, now is the time to do so!

Download the Wellness at Your Side app:

WELL-BEING AND MORE

There is also a financial reward for participating.

To learn how you can earn up to a $1,000 contribution to your HSA or HRA, visit https://bhr.sd.gov/benefits/livewellsd/.

Take the first step towards better well-being and rewards by scheduling your annual wellness preventive exam and complete the biometric screening form with your provider.

On the LiveWellSD Portal you will find:

• Individual and team challenges

• Mental health podcasts

• Motivated coaching via phone or messaging

• Well-being webinars

• Health tracking & device connection

• Information about diabetes prevention

• And much more!

BETTER WELL-BEING BRINGS REWARDS

• Increased energy

• Decreased stress

• More restful sleep

• Decreased risk of illness and injury

• Improved immunity

• Increased longevity

• A happier and more fulfulling life

�Visit the Apple or Google Play store and search "Wellness at Your Side"

�Download the app to your mobile device and enter the connection code: southdakota https://bhr.sd.gov/benefits/livewellsd/

SUPPORTING HEALTHY

PREGNANCIES

State employees and any covered spouses and/or dependents can access additional resources for a healthy pregnancy. The Pregnancy Support Program is free, and it’s here for you now and after your baby is born.

HOW IT WORKS

Call the number on your Wellmark ID, and a Pregnancy Support advocate will connect you with tools and resources, including:

Pregnancy assessment: Complete this online assessment within the first 12 weeks of your pregnancy to receive a $250 wellness incentive.

After your baby arrives, you can qualify for another $250 incentive by taking a postpartum assessment.

WebMD® Pregnancy Assistant:

Provides information about your pregnancy and the stages of your baby’s growth.

Count the Kicks® app: Helps you keep track of your baby’s normal movement patterns.

Text4BabySM: A texting tool that delivers appointment reminders, safety information, and updates on your baby’s milestones.

BeWell 24/7: A phone line that connects you with a nurse for one-on-one support day and night.

Note: You must register within the first 12 weeks of pregnancy to be eligible for the initial incentive.

In addition to helpful tools and Care Team support, when you participate in the Pregnancy Support Program, the cost share for your first and second trimester ultrasound is waived.

CARE CAN BE COMPLICATED. SUPPORT IS JUST ONE CALL AWAY

Major illnesses, injuries, and chronic conditions can be overwhelming. From the complexities of the healthcare system to the challenges of staying on track with your treatment plan, navigating your care can feel like a full-time job.

YOUR HEALTH BENEFITS CAN HELP

You need advocates who will work on your behalf, ensuring you’re getting the care you need so you can focus on getting or staying healthy. And, you need to be able to find them all in one place. That’s why your health benefits include the Wellmark Care Team.

ONE CALL FOR EVERY CONDITION

With the Wellmark Care Team, you will have a dedicated case manager and an integrated team of specialists including nurses, pharmacists, behavioral health specialists, and care advocates who are here to help — and they’re accessible any time by calling the number on the back of your Wellmark ID.

With just one call to Wellmark’s State of South Dakota Care Team line, anyone can get support, including members who experience:

The Wellmark Care Team

�1 blood glucose meter 150 testing strips 150 lancets 1 lancing device

�1 USB charger 1 carrying case Instructions 2 bottles of control solution

Serious illnesses High-risk pregnancies Premature babies Complex chronic conditions including heart disease, asthma, and others

Transplants Traumatic injuries Major surgeries Cancer Behavioral health conditions, and more

HOW TO PARTICIPATE

If you have a health condition, you can call the Wellmark Care Team at any time to request support. Wellmark will also reach out to members who are identified for program participation through hospital admission notifications, health and pharmacy claims information, and through provider referral.

This program is free, voluntary, and confidential. To learn more or to enroll, call 800.846.9183.

RARE CONDITION MANAGEMENT

This new no-cost program is available to any member with one of nine conditions. The goal of this program is to provide you with another level of help for your condition and to compliment what you already have through Wellmark.

Covered conditions include Crohn's disease, Cystic fibrosis, Gaucher's disease, Hemophilia, Hereditary angioedema, Multiple Sclerosis, Rheumatoid arthritis, systemic lupus erythematosus (SLE or lupus), and Ulcerative colitis.

DIABETES PREVENTION AND DIABETES MANAGEMENT WITH

LIVONGO

We're pleased to offer two no-cost options for diabetes care through Livongo, a holistic program that can offer assistance to benefitted members living with or trying to prevent the onset of diabetes.

Livongo Diabetes Prevention is a healthy lifestyle change program that helps you lose weight and prevent the onset of type 2 diabetes.

Livongo Diabetes Management is a program helps make living with diabetes easier by providing you with a connected meter, unlimited strips and lancets

Dental care is an important part of your overall health. Your benefits package includes dental insurance options with low- or no-cost preventive care, as well as coverage for basic services, major services, and orthodontics. Here are some important things to know about your coverage.

�As a value to you, the State subsidizes a cost share of $25.32 per month, regardless of which plan or coverage level you choose. The premiums published include the subsidy, and therefore, reflect the premium you will pay.

�You can visit any dentist you choose, but you may pay less when you go to an in-network provider. Participating in-network dentists have agreed to write off charges that exceed the amounts allowable by the plan. Out-of-network dentists can bill you for the remaining amount.

�There is no waiting period for services.

�Orthodontic cases may be paid for over two years based on the treatment plan.

�Delta Dental will pay $1,000 for orthodontics in the first year on the Enhanced Plan. To receive the additional $1,000 payment in the second year, you must continue to be enrolled in the Enhanced Plan.

�Premiums are paid with pre-tax deductions.

Questions? Learn more about your dental benefits at https://bhr.sd.gov/benefits/flexible-benefits/dental/ or at deltadentalsd.com.

Dental Plans

Administered by Delta Dental of South Dakota

To locate in-network providers near you, visit deltadentalsd.com and click on Find a Dentist.

BASE PLAN ENHANCED PLAN

24 PAY

PERIODS

12 PAY

PERIODS

24 PAY

PERIODS

12 PAY

PERIODS

Employee $6.81 $13.62 $18.51 $37.02

Employee + spouse $26.23 $52.46 $49.56 $99.12

Employee + child(ren) $29.90 $59.80 $50.78 $101.56

Family $49.32 $98.64 $81.85 $163.70

Deductible $25 per covered person N/A

Annual maximum benefit1

$1,000 per covered person

$2,000 per covered person

Lifetime orthodontic benefit

N/A $2,000

Maximum Bonus Account (MBA) limit

N/A $2,000

1. �All services (except diagnostic, preventive and orthodontics) are subject to the annual maximum and will not be paid if your annual maximum has been reached.

DENTAL CARE AND SERVICES

BASE PLAN ENHANCED PLAN

Percentage your plan pays after the deductible is met

Percentage your plan pays

Preventive care Routine cleaning and examinations (two per plan year), fluoride treatments (two per plan year up to age 19), bite-wing X-rays (one per plan year), full mouth X-rays (one every five years), space maintainers (on primary back teeth, up to age 14), and dental sealants (for unrestored first and second permanent molars, up to age 16). These services do not apply to the Annual Maximum Benefit.

75% 100%

Basic services Stainless steel crowns, silver and tooth-colored fillings, non-surgical extractions, emergency treatment, periodontal maintenance cleanings, denture repair, and anesthesia in conjunction with surgical services.

60% 80%

Major services Root canals, treatment of diseases of the tissues supporting the teeth, crowns, bridges, dentures, implants, and surgical extractions.

35% 50%

Orthodontics N/A 50% For patients of any age

Additional Dental Benefits

MAXIMUM BONUS ACCOUNT (MBA) BENEFITS

Administered by Delta Dental

Employees enrolled in the Enhanced Plan for dental coverage and their dependents are eligible for Maximum Bonus Account (MBA) benefits. With MBA benefits, each covered person who qualifies will receive $250 per plan year to pay for dental care. Employees can accumulate up to the $2,000 in their MBA account.

Here’s what else you need to know about MBA benefits:

��You must be enrolled in the Enhanced Plan for one plan year before you can earn MBA benefits.

�Your MBA account balance rolls over from year to year.

�You, your spouse, and your dependents will each have their own account. MBA benefits cannot be shared.

��MBA benefits cannot be used for orthodontic claims.

�You will lose your account balance if you move from the Enhanced Plan to the Base Plan, or if you have a break in coverage.

Questions about MBA benefits? Call Delta Dental at 1.877.841.1478, or visit https://southdakota.deltadental.

com/shop-dental-plans/features-and-options/maximum-bonus-account/.

PREVENTION PAYS

Administered by Delta Dental

The Prevention Pays feature exempts preventive care and some gum disease (periodontal) services from the calculation of the plan's annual maximum benefit.

That means preventive services like exams, x-rays, and periodontal maintenance cleanings are covered even when the plan's annual maximum benefit has been reached. It also means more benefits are available to help pay for treatment procedures like cavity fillings, crowns, and root canals.

HEALTH THROUGH ORAL WELLNESS®

Administered by Delta Dental Health through Oral Wellness is a unique program that adds benefits to your dental plan based on your oral health needs.

There is no need to enroll, and it is provided at no cost to you.

A Delta Dental network dentist trained in Health through Oral Wellness will assess your risk for tooth decay and periodontal disease during a regular preventive visit. Depending on your level of risk, your dentist will recommend additional benefits you are eligible for, including additional cleanings*, fluoride treatments, sealants, and oral hygiene instruction.

Also, if you have any of the following health conditions, you are eligible for additional benefits:

�Pregnancy: One additional cleaning during your pregnancy �Diabetes: Two additional cleanings �High-risk cardiac care: Two additional cleanings �Kidney failure or dialysis: Two additional cleanings �Rheumatoid arthritis: Two additional cleanings ���Stroke: Two additional cleanings �Cancer-related chemotherapy or radiation: Two additional cleanings and two applications of fluoride �Suppressed immune system: Two additional cleanings and two applications of fluoride

Learn more: https://southdakota.deltadental.com/shop-dental-plans/features-and-options/health-through-oral-wellness/.

*Cleanings may be either a general cleaning (prophylaxis) or a periodontal maintenance cleaning, depending on your dentist’s recommendation.

To qualify for MBA benefits, you must:

1. Enroll in the Enhanced Plan for at least one year before earning benefits.

2. �File at least one non-orthodontic claim during the plan year.

3. �Use less than $1,000 (half of your annual maximum benefit) for the plan year.

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Along with the one eye exam covered annually on your…