ESSENTIAL PLAN
SELECT PLAN
CHOICE PLAN
ULTRA / ULTRA II PLAN
RESERVE PLAN
(HSA QUALIFIED)
$1000, $1250, $1500, $2000 or $2500
$200, $250, $500, $750, $1000,
$1250, $1500, $2000, $2500, $3000,
$5000, $7500 or $10000
$200, $250, $500, $750, $1000,
$1250, $1500, $2000, $2500, $3000,
$5000, $7500 or $10000
$500, $750,$1000, $1250, $1500, $2000,
$2500, $3000 or $5000
$1250, $1500, $2000, $2500, $2900,
$4000 or $5950
$200, $250, $300, $400 or $500
$200, $250, $300, $400 or $500
$200, $250, $300, $400 or $500
NA
NA
80%/20% to $500, $1000, $1500,
$2000, $3000
70%/30% to $1500, $2250, $3000
60%/40% to $2000, $3000
50%/50% to $4000, $5000
80%/20% to $500, $1000, $1500,
$2000, $3000
70%/30% to $1500, $2250, $3000
60%/40% to $2000, $3000
50%/50% to $4000, $5000
80%/20% to $500, $1000,
$1500, $2000, $3000
70%/30% to $1500, $2250, $3000
60%/40% to $2000, $3000
50%/50% to $4000, $5000
80%/20% to $500, $1000,
$1500, $2000, $3000
70%/30% to $1500, $2250, $3000
60%/40% to $2000, $3000
50%/50% to $4000, $5000
100%/0%*
80%/20% to $500, $1000, $1500,
$2000, $3000, $4000
70%/30% to $1500, $2250, $3000
60%/40% to $2000, $3000
ANNUAL DEDUCTIBLE (Benefit Year)
Deductibles are shown as individual for Essential, Select, Choice and
Ultra/Ultra II Plans and as single for Reserve Plan. Family Deductibles
of 2x or 3x are available in Essential, Select, Choice and Ultra/Ultra II
Plans. Reserve Plan family Deductible is aggregate.
MONTHLY DEDUCTIBLE (Benefit Month)
Deductibles are shown as single. Family Deductible is 2x or 3x.
COINSURANCE MAXIMUM (Benefit Year)
Coinsurance Maximums are shown as individual for Essential, Select,
Choice and Ultra/Ultra II Plans and as single for Reserve Plan. Family
Coinsurance maximum of 2x or 3x will mirror selected Annual or Monthly
Deductible option for Essential, Select, Choice and Ultra/Ultra II Plans.
Reserve Plan family Coinsurance Maximum is aggregate.
OUT-OF-POCKET MAXIMUM
ANNUAL MAXIMUM BENEFIT (per Benefit Year)
PHYSICIAN OFFICE VISITS
PREVENTIVE HEALTH SERVICES
LAB AND X-RAY
The portion of payments for health services which is the responsibility of the Member, which shall include Deductible and Coinsurance. Annual Out-of-Pocket
Maximum can range from $700 to $15,000 depending on the deductible and coinsurance options selected.
$2,000,000
Coinsurance % after deductible
$2,000,000
$2,000,000
$2,000,000
$2,000,000
Coinsurance % after deductible
$25 copay (office visit component) / 100%
(deductible waived)
Ultra: $30 copay / 100% (deductible waived)
Ultra II: $30 primary care physician copay
$50 specialist physician copay
100% (deductible waived)
Coinsurance % after deductible
Covered preventive health services provided by a Participating Provider are not subject to Deductible, Coinsurance or Copayment.
A complete list of available Preventive Health Services is located online at www.dakotacare.com.
Ultra: $30 copay / 100% (deductible waived)
Ultra II: $30 primary care physician copay
$50 specialist physician copay
100% (deductible waived)
If service provided at physician office or
independent x-ray/lab facility. Otherwise,
coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
$4000 normal/$8000 cesarean section
delivery copay / 100% (deductible waived)
Coinsurance % after deductible
Coinsurance % after deductible
HOSPITAL SERVICES
Inpatient or Outpatient
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
ANESTHESIA
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
OUTPATIENT SURGERY
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
$300 copay
then coinsurance % after deductible
$150 copay
then coinsurance % after deductible
(copay waived if admitted)
$150 copay
then coinsurance % after deductible
(copay waived if admitted)
$150 copay
then coinsurance % after deductible
(copay waived if admitted)
Coinsurance % after deductible
Coinsurance % after deductible
(limited to $2000 per benefit year)
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
(Mental health coverage only available for
biologically based conditions)
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
$150 copay
then coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
Please refer to the Essential Group Plan
Summary of Pharmacy Benefits
Rider may be purchased
Rider may be purchased
Rider may be purchased
Coinsurance % after deductible
Coinsurance % after deductible
Coinsurance % after deductible
$25 copay (office visit & manipulation
components) / 100% (deductible waived)
$30 copay / 100%
(deductible waived)
Coinsurance % after deductible
MATERNITY CARE
EMERGENCY ROOM
AMBULANCE TRANSPORT
HOME HEALTH CARE
MENTAL HEALTH AND
SUBSTANCE USE DISORDERS
Inpatient, Outpatient or Partial Hospital Care
DURABLE MEDICAL EQUIPMENT
AND PROSTHETICS
HOSPICE
PRESCRIPTION DRUGS
(Subject to DAKOTACARE Formulary)
CHIROPRACTIC
(Visit Limits Apply per Benefit Year)
* Coinsurance option is only available on plans which include a $2500, $2900, $4000 or $5950 single deductible ($5000, $5800, $8000 or $11900 family deductible).
Coinsurance % after deductible
Coinsurance % after deductible
This information is a summary of coverage. Benefits are based on services obtained through a Participating Provider. Please see Master Contract for actual benefits, limitations, exclusions and preauthorization requirements.
OPTIONAL COVERAGES
(*Underwritten by carriers other than DAKOTACARE)
Optional Riders available to groups include Vision and
Supplemental Accident. Please refer to each Rider for
specific coverages and benefits available.
*Dental Insurance offers exceptional coverage at very
affordable rates. Best of all, it is a voluntary program – which
means there is no cost to you, the employer!
*Group Term Life and AD&D Insurance provides
inexpensive life coverage for your employees.
*Supplemental Life Insurance is available to provide
additional group term life insurance for employees, their
spouses and children on an employee paid basis.
PLAN HIGHLIGHTS
DAKOTACARE
South Dakota’s Most Powerful Health Care Network:
Your employees have “freedom of choice” from 100% of
hospitals and more than 98% of South Dakota’s physicians
and pharmacies.
“No Paperwork – No Hassle” claims processing! When
you see a DAKOTACARE provider, just present your
DAKOTACARE card and we’ll do the rest!
Prevention is the key to staying healthy! All of
DAKOTACARE’s plans include Preventive Health Services
without cost-share to our members. A complete list of
available Preventive Health Services is located online at
www.dakotacare.com.
DAKOTACARE’s network includes dozens of specialized
Organ Transplant Centers across the country to serve the
needs of transplant patients.
Exceptional Customer Service is our pride and joy. Our
home and branch offices and entire staff are located in South
Dakota, making us responsive and easy to contact – which, of
course, means better service!
DAKOTACARE FLEX is an employee benefit program
designed to help you and your employees save money
by paying for group health care and other premiums,
unreimbursed medical expenses and dependent care
expenses with BEFORE-TAX dollars.
DAKOTACARE Value Plus offers members discounted rates
on vision services, travel assistance, identity theft restoration
and weight loss management. Members may visit a network
provider and receive discounted rates on services and
supplies for themselves, their spouse and children. There is
no extra charge and no limitations on how often a member
may use the Value Plus discounts.
*Dependent Life Insurance is available for your employees’
spouses and dependents.
*Short-Term and Long-Term Disability policies are available
to give you and your employees peace of mind.
We a
re
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akota’s Health Plan.a
*Cancer & Specified Disease Insurance offers the additional
coverage you need for the hidden costs of cancer and 30
other diseases.
*Accident Insurance provides on and off-the-job benefits
due to an injury or accident and includes a disability income
benefit.
*Long-Term Care Insurance provides comprehensive
benefits for skilled, intermediate and custodial care.
DAKOTACARE COBRA Administrative Services offer
employers complete administration and management
services for benefits mandated under COBRA and state
continuation laws.
DAKOTACARE’s Population Health is a personalized
journey toward better health for you and your employees.
Whether it’s a company-wide wellness initiative or an
individualized disease management program, Population
Health is here for you.
Disease Management programs are designed to help
members improve their quality of life with less family
disruption and stress. Population Health Disease
Management Programs:
• Heartline
• Asthma Care • Diabetes Care
Proactive Health programs provide members help to
improve the probability of normal births, as well as access
to healthcare resources for the self-care of minor health
problems. Population Health Proactive Health Programs:
• Prenatal Partners, including Text4Baby
• Taking Care Books and Monthly
Newsletters and E-Newsletters
Health and Wellness programs are personalized to your
company’s unique circumstances by certified experts who
will assess your needs and create a program specific to
your employees. Population Health resources:
• Health Assessments and Screenings
• Wellness Programs and Education
• Preventive Care Benefits
• Tobacco Cessation
The Taking Care Newsletter is a monthly publication that
is distributed through DAKOTACARE. Taking Care offers
employers and employees valuable health information,
nutrition tips and timely medical news to help keep them,
and their families, healthier.
DAKOTACARE is the Health Care Plan of the South Dakota Medical Association, established by South Dakotans to respond to South Dakota health care
issues.
We know what it takes to create affordable solutions to the health care problems right here in our state. Not some other state.
Our mission is to provide excellent service to our customers and to continually improve the health of our members by assuring that quality, affordable health care
services are delivered to our members through a comprehensive network of physicians and other health care providers.
Plus, our home and branch offices and entire staff are located in South Dakota, making us responsive and easy to contact. Which, of course, means better
service. Our clients wouldn’t have it any other way.
2600 W. 49th Street l Sioux Falls, SD 57105
605.334.4000 l 800.325.5598 l www.dakotacare.com
© Copyright 2012
Benefits effective 1/1/2013
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