Human Resource Services

Wellmark Program 3 Plus (Indemnity Plan)

Plan Information Effective: January 1, 2017 through December 31, 2017

Plan Details

• For office visits, you pay a $15 office visit copayment once per date of service for the exam only. No coinsurance or deductible follows this copayment.
• The plan pays 80% of covered charges. You pay the rest (20%).
• For inpatient services, you pay for covered expenses until those expenses reach the deductible ($300 for single contracts or $400 for family contracts).
• All deductibles, coinsurance, and copayments go toward the medical out-of-pocket limit (Separate out-of-pocket maximum for prescription drugs).
• No annual or lifetime maximum benefit limits. However, certain services do have limits; for example, only one physical per year is covered.
• The pre-existing condition waiting period for new employees is 11 months. (This may be offset by proof of creditable coverage.)
• You may go to any licensed physician or hospital. Although the majority of health care providers do accept this type of insurance, some health care providers do not participate with Wellmark BCBS. If you go to a nonparticipating provider, you could be responsible for paying an additional amount out of your pocket, as that provider has not agreed to Wellmark’s payment. Anything above what Wellmark allows is your responsibility.
• Your prescription drug benefits are provided through a three-tier program. This means you pay a copayment at the time you receive your prescription until you reach your separate prescription drug out-of-pocket limit. The amount of the copayment is determined by the drug you receive. Copayment amounts are:
  • $5 for preferred generic drugs
  • $15 for preferred brand name drugs
  • $30 for non-preferred brand name drugs and non-preferred generic drugs.
    If a generic equivalent is appropriate and available and you choose a brand name drug, you are responsible for the copayment plus any difference between the maximum allowable fees for the generic and brand name drug, even if the provider has specified that the brand name drug must be taken. You will be required to pay this difference even after you have reached your separate prescription out-of-pocket limit.
• There is a separate ($500/$1,000) out-of-pocket maximum for prescription drugs. This separate out-of-pocket limit does NOT apply to the medical out-of-pocket limit.

Wellmark Iowa Select (PPO)

Plan Information Effective: January 1, 2017 through December 31, 2017

Plan Details

Iowa Select, the Wellmark BCBS Preferred Provider Organization (PPO), is similar to the Program 3 Plus plan, with one major difference. Iowa Select contracts with health care providers (hospitals, doctors, etc.) for reduced fees for each type of service. These savings are passed on to you with lower coinsurance rates (10%) if you use the network providers. You may use out-of-network providers (providers who are not part of the PPO), but then you will pay a higher coinsurance rate (20%) and are subject to the deductible.

Other Iowa Select provisions include:

• For office visits, you pay a $15 office visit copayment once per date of service for the exam only. No coinsurance or deductible follows this copayment.
• A $250 annual deductible for single coverage, which applies to both inpatient and outpatient services. The family deductible is $500.
• The deductible is waived for any services provided in the office or clinic setting of an Iowa Select physician.
• All deductibles, coinsurance, and copayments go toward the medical out-of-pocket limit (Separate out-of-pocket maximum for prescription drugs). However, certain services do have limits; for example, only one physical per year is covered.
• The pre-existing condition waiting period for new employees is 11 months. (This may be offset by proof of creditable coverage.)
  • If you use network providers, you do not need to submit claim forms. The provider will do that for you.
• If you do not use network providers, you are responsible for the deductible, 20% coinsurance, plus any amount above Wellmark’s allowable amount.
• Your prescription drug benefits are provided through a three-tier program. This means you pay a copayment at the time you receive your prescription until you reach your separate prescription drug out-of-pocket limit. The amount of the copayment is determined by the drug you receive. Copayment amounts are:
  • $5 for preferred generic drugs
  • $15 for preferred brand name drugs
  • $30 for non-preferred brand name drugs and non-preferred generic drugs.
    If a generic equivalent is appropriate and available and you choose a brand name drug, you are responsible for the copayment plus any difference between the maximum allowable fees for the generic and brand name drug, even if the provider has specified that the brand name drug must be taken. You will be required to pay this difference even after you have reached your separate prescription out-of-pocket limit.
• There is a separate out-of-pocket limit ($500/$1,000) for prescription drugs. This prescription out-of-pocket limit does not apply toward the medical out-of-pocket limit.

Wellmark Blue Access – Managed Care Organization (MCO)

Plan Information Effective: January 1, 2017 through December 31, 2017

Plan Details

Blue Access allows you to obtain care from any provider who participates in the MCO’s network (Iowa and bordering counties). No Designated Personal Doctor referral is required.

Other MCO provisions include:

• No required deductibles. However, there are coinsurance and copayments that vary by service provided.
• Your prescription drug benefits are provided through a three-tier program. This means you pay a copayment at the time you receive your prescription. The amount of the copayment is determined by the drug you receive. Copayment amounts are:
  • $5 for preferred generic drugs,
  • $15 for preferred brand name drugs, and
  • $30 or 25% (whichever is higher) for non-preferred brand name drugs and non-preferred generic drugs.
    The prescription must be for a covered service and from a participating plan pharmacy. No ancillary charges may be assessed.
• There is a separate out-of-pocket limit ($5,850/$11,700) for prescription drugs. This prescription out-of-pocket limit does not apply toward the medical out-of-pocket limit.
• There are no annual or lifetime maximum benefit limits. However, certain services do have limits; for example, only one physical per year is covered.
• Emphasis on preventative services, with 100% coverage for an annual physical, well baby care, screening mammograms, and disease management programs.
• No pre-existing condition waiting period for new employees.
• If you receive care from an out-of-network provider, unless it is an emergency, you are responsible for full payment.