The South Dakota Farm Bureau Health Plans (SDFBHP) Major Medical plan is ideal for those who want catastrophic protection with the advantage of a lower cost. This plan provides benefits for physician services, hospitalization, prescription drugs and more. Available for individuals or families.
SDFBHP uses UnitedHealthcare ChoicePlus Network. Please keep in mind that in-network payments are based on negotiated fees. If an out-of-network provider is used, the member’s liability will increase significantly.
About the Plan
As long as you make premium payments on time and do not file claims with false or misleading information you’ll have the security of SDFBHP Medicare Supplement plan.
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Major Medical Plan Overview
Deductible
$7,500
Out-of-Pocket Max
Individual
$15,000
Family
$30,000
Lifetime Benefit Max
Unlimited
Major Medical Plan Details
Note: The benefits and costs shown are for plans effective on or after January 1, 2022.
Overview
| In-Network | Out-of-Network | |
|---|---|---|
Calendar Year Deductible1 (CYD) +Unless otherwise indicated, all benefits are subject to CYD. | $7,500 per member | $7,500 per member |
| Out-of-Pocket Maximum2 (OOP) | $15,000 Individual $30,000 Family | Unlimited |
Footnotes
1 Deductible – the dollar amount of covered services that must be incurred and paid first by a member each calendar year before plan benefits begin.
2 Once the OOP maximum is met, benefits are provided at 100% for a member(s) for the remainder of the calendar year. This applies to in-network provider services only. There is no Out of Pocket Maximum when out of network providers are used.
Services
| In-Network | Out-Of-Network | |
|---|---|---|
| TelaDoc | No Charge | No coverage |
| Coinsurance
+Based on the maximum allowable charges for eligible benefits. |
Plan pays 80%, you pay 20% | Plan pays 60%, you pay 40% |
Preventive Care Benefits
No Waiting Period| In-Network | Out-Of-Network | |
|---|---|---|
| Well Child Services 3 | Plan pays 80%, you pay 20% | Not Covered |
| Routine Colonoscopy 4 | Plan pays 80%, you pay 20% | Plan pays 60%, you pay 40% |
| Annual Routine PSA 5 | Plan pays 80%, you pay 20% | Plan pays 60%, you pay 40% |
| Annual Routine OB/GYN Exam 6 | Plan pays 80%, you pay 20% | Not Covered |
| Annual Routine Pap Smear 7 | Plan pays 80%, you pay 20% | Plan pays 60%, you pay 40% |
| Mammogram 8 | Plan pays 80%, you pay 20% | Plan pays 60%, you pay 40% |
Prescription Drug Coverage
Unlimited Calendar Year Maximum Per Member| In-Network | Out-Of-Network | |
|---|---|---|
| Generic 30 Day Supply | Plan pays all but copayment, you pay $4 copayment 9 | Plan pays 60%, you pay 40% |
| Brand | Plan pays 80%, you pay 20% | Plan pays 60%, you pay 40% |
Footnotes
3 Benefits are available, subject to deductible and coinsurance, for a member under the age of seven for physical examinations and appropriate immunizations/vaccinations when services are rendered by an in-network provider. Exams not used during the time periods below do not carry over to the next time period.
| Age | Number of Exams |
|---|---|
| Under age one | four exams from birth to the child’s first birthday |
| Age one | two exams from the child’s first birthday to the child’s second birthday |
| Age two through six | one exam per year (determined by the child’s birthday) |
4 Benefits will be provided for one routine colonoscopy every four years for members age 50 and over when provided by an in-network or out-of-network provider, subject to the deductible and coinsurance.
5 Benefits will be provided, subject to deductible and coinsurance, for one routine PSA per calendar year when services are rendered by an independent laboratory or other outpatient setting.
6 Benefits will be available for one routine OB/GYN exam per calendar year, subject to deductible and coinsurance. Services must be rendered by an in-network physician’s office and billed by the in-network provider. Related pathology, including pap smear, which is provided as a part of the routine OB/GYN exam, will be covered when the services are rendered by an in-network physician’s office and billed by the in-network provider. Related pathology that the physician sends to an independent laboratory will be subject to deductible and coinsurance. No benefit is available for routine OB/GYN exams provided by an out-of-network provider.
7 Benefits will be provided for the interpretation of one routine pap smear per calendar year when services are rendered by an independent laboratory or other outpatient setting, subject to deductible and coinsurance.
8 Benefits will be provided, subject to deductible and coinsurance, for routine mammography screening provided such examinations are conducted upon the recommendation of the member’s physician. One baseline routine mammogram will be allowed for members between the ages of 35-39. One routine mammogram will be allowed annually for members age 40 and above. All routine mammography screens are subject to deductible and coinsurance.
9 Prescription copayment does not apply toward deductible or out-of-pocket maximum.
Pre-Existing Condition Waiting Period
Benefits will not be provided for any pre-existing condition until a member has completed a waiting period of at least 6 months. A pre-existing condition is defined in the contract as “An illness, injury, pregnancy or any other medical condition which existed at any time preceding the effective date of coverage under this contract for which: Medical advice or treatment was recommended by, or received from, a provider of health care services; or symptoms existed which would cause an ordinarily prudent person to seek diagnosis, care or treatment.
Office Copayment Guidelines
Maternity Benefits
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