FEHB 2002 Logo

Plan Profile

 Accessible site Printer Friendly Copy
You are here: FEHB Home > 2002 Plan Comparison > South Dakota > Plan Profile: Sioux Valley Health Plan

General Information
__ __
Plan Name: Sioux Valley Health Plan
Service Area: Eastern/Central/Rapid City areas
Brochure: PDF Version
Brochure: Text Version
NCQA Accreditation: Yes
JCAHO Accreditation: Yes
URAC Accreditation: No
Plan Type: POS
Enrollment Code-Self: AU1
Enrollment Code-Self & Family: AU2
Link to Plan Home Page: http://www.siouxvalley.org
Telephone: 800/752-5863
__ __

Benefits
__ __
In Network - Doctor Care/ Primary Office Visits: $10
In Network - Hospital Inpatient Room and Board Charges: $100
In Network - RX/ Generic/ Retail: $10
In Network - RX/ Brand/ Retail: $20
In Network - RX/ Brand/ NonFormulary: $20
Out of Network - Doctor Care/ Primary Office Visits: 40%
Out of Network - Hospital Inpatient Room and Board Charges: 40%
Out of Network - RX/ Generic/ Retail: 40%
Out of Network - RX/ Brand/ Retail: 40%
Out of Network - RX/ Brand/ NonFormulary: 40%
__ __

Rates
__ __
Non-Postal
___Biweekly Self: $56.16 Self: & Family: $106.21
___Monthly Self: $121.68 Self: & Family: $230.12
___Twice Biweekly Self: $112.32 Self: & Family: $212.42
_
Annuitants
___Monthly Self: $121.68 Self: & Family: $230.12
_
U.S. Postal Service Employees (Type A)
___Monthly Self: $83.42 Self: & Family: $142.72
___Biweekly Self: $38.50 Self: & Family: $65.87
_
U.S. Postal Service Employees (Type B)
___Monthly Self: $97.04 Self: & Family: $204.71
___Biweekly Self: $44.79 Self: & Family: $94.48
_
Worker's Compensation Recipients
___Twice Biweekly Self: $112.32 Self: & Family: $212.42
_
Certain Temporary Employees
___Biweekly Self: $154.02 Self: & Family: $329.62
___Monthly Self: $333.71 Self: & Family: $714.18
_
Former Spouse Enrollees
___Monthly Self: $333.71 Self: & Family: $714.18
___Biweekly Self: $154.02 Self: & Family: $329.62
_
Temporary Continuation of Coverage
___Monthly Self: $340.38 Self: & Family: $728.46
___Biweekly Self: $157.10 Self: & Family: $336.21
_
FDIC
___Biweekly Self: $38.50 Self: & Family: $65.87
_
 __ __