| Plan Provisions |
Wellmark Blue Access and Blue Advantage |
BC/BS
Iowa Select |
BC/BS
Program III Plus
|
| Monthly Employee Premium after UI Contribution |
Single: $0.00
Family: $0.00 |
Single: $0.00
Family: $264.58 |
Single: $0.00
Family: $270.20 |
| Care Providers |
Care from network providers ONLY; Life-threatening emergencies covered anywhere |
Any provider; Select providers have lower co-insurance percentage and deductible is waived for services in the office setting |
Any provider; BlueCross/BlueShield (BC/BS) providers can result in lower out-of-pocket expenses |
| Benefits Available from Non-member Providers |
None without prior approval |
Normal plan benefits; For non-BC/BS providers, employee pays charges over usual reasonable and customary limit |
Normal plan benefits; For non-BC/BS providers, employee pays charges over usual reasonable and customary limit |
| Deductible Single/Family |
None |
$250 / $500; Deductible is waived for Select providers only if service is in office setting |
$300 / $400 inpatient services only |
| Co-insurance Percentage |
20% in limited situations |
Select: 10%;
Non-Select: 20% |
20% |
Out-of-Pocket Limit
Single/Family |
$750 / $1500
(except prescription drugs) |
$600 / $800
($250 / $500 for prescription drugs) |
$600 / $800
($250 / $500 for prescription drugs |
| Pre-existing Condition Waiting Period |
None |
11 months; none for dependents under age 19 |
11 months; none for dependents under age 19 |
| Pre-approval of Inpatient Admissions |
Required (Plan physician will determine) |
Required (Subscriber must obtain approval from BC/BS) |
Required (Subscriber must obtain approval from BC/BS) |
| Second Surgical Opinion |
Voluntary |
Voluntary |
Voluntary |
| Outpatient Surgery |
Plan physician will determine, 0% |
Mandatory for certain procedures; Paid according to normal plan benefits when procedure done on outpatient basis; 50% benefit reduction on all associated hospital and surgical services for non-compliance; Select 10%;
Non-Select 20% after deductible |
Mandatory for certain procedures; Paid according to normal plan benefits when procedure done on outpatient basis; 50% benefit reduction on all associated hospital and surgical services for non-compliance, 0% |
| Office Calls |
$10 co-payment per visit |
Select: $15 co-payment per visit & 10%
Non-Select: $15 co-payment per visit & 20% |
$15 co-payment per visit & 20% |
| Routine Physicals |
$10 co-payment per visit |
$15 co-pay and
Limit one physical per member per year
Select: 10%;
Non-Select: deductible then 20% |
$15 co-pay and 20%; Limit one physical per member per year |
| Well Baby Care |
$10 co-payment per visit |
$15 co-pay and
Select: 10%;
Non-Select: 20% to 7 years of age |
20% to 7 years of age |
| X-Ray and Lab |
0% |
Select: Deductible waived if in office setting then 10%;
Non-Select: deductible then 20% |
20% |
Routine Eye /
Hearing Exam |
$10 co-payment;
One exam covered per calendar year |
Limit one exam per year; $15 co-pay and
Non-Select: 20% |
Not covered |
| Maternity |
$10 co-payment for initial visit |
Select: 10%;
Non-Select: deductible then 20% |
20%; No deductible for physician charges for pre-/post-natal visits and delivery |
| Infertility |
Not covered |
Select: 10%;
Non-Select: deductible then 20%;
$25,000 lifetime maximum per couple |
20%;
$25,000 lifetime maximum per couple |
| Miscellaneous Services |
Wellmark Blue Access and Blue Advantage |
BC/BS
Iowa Select |
BC/BS
Program Three Plus |
| Prescription Drugs |
$5 co-payment preferred generic drugs;
$15 co-payment preferred brand name drugs;
$30 or 25% co-payment non-preferred drugs;
(does not apply to out-of-pocket maximum) |
$5 co-payment preferred generic drugs;
$15 co-payment preferred brand name drugs;
$30 co-payment non-preferred drugs;
Separate $250/$500 out-of-pocket maximum |
$5 co-payment preferred generic drugs;
$15 co-payment preferred name brand drugs;
$30 co-payment non-preferred drugs;
Separate $250/$500 out-of-pocket maximum |
| Immunizations |
0% |
Select: 0%;
Non-Select: 10% |
20% |
| Allergy Treatments |
$10 co-payment per visit |
Select: 10%;
Non-Select: deductible then 20% |
20% |
| Chiropractor |
$10 co-payment per visit;
Prior approval may be required |
Select: 10%;
Non-Select deductible then 20% |
20% |
| Home Health Care |
0% if authorized |
Select: deductible then 10%;
Non-Select: deductible then 20%
Pre-certification required |
20%;
Pre-certification required |
Eyeglasses /
Hearing Aids |
Not covered |
Not covered |
Not covered |
| Ambulance |
0% if medically necessary |
Deductible then 20% |
20% |
| Organ Transplants |
0% if authorized |
Prior approval required |
Prior approval required |
| Skilled Nursing Facility |
0% for facility;
$10 co-payment for physician visit;
120 day maximum;
Pre-approval required |
Select: deductible then 10%;
Non-Select: deductible then 20%;
Unlimited days;
Pre-certification required |
20% after deductible;
$300 single / $400 family;
No limit on days;
Pre-certification required |
| ER Care |
$50 co-payment per visit (waived if admitted) |
$50 co-payment per visit (waived if admitted) and co-insurance |
0% |
| Physical Therapy |
$10 co-payment per visit;
60 visit maximum |
Select: deductible then 10%;
Non-Select: deductible then 20% |
20% |
| Accidents |
Office-$10 co-pay |
$15 co-pay plus Select: 10%;
Non-Select: deductible then 20% |
0% for treatment within 72 hours |
| Hospice Care |
0%; Prior approval required |
Select: deductible then 10%;
Non-Select: deductible then 20%
Pre-certification required |
20%; Pre-certification required |
| Durable Medical Equipment |
20%; Prior approval required |
Select deductible then 10%;
Non-Select: deductible then 20% |
20% |
| Speech, Occupational, and Respiratory Therapy |
$10 co-payment;
60 visit maximum (of each type);
Prior approval required |
Select: deductible then 10%;
Pre-approval required;
Non-Select: deductible then 20%; Pre-approval required |
20%;
Pre-approval required;
Must be hospital-based billed |
| Dental Accident Care |
20% if authorized;
Within 6 months of injury |
Select: 10%;
Non-Select: deductible then 20%;
Within 72 hours of accident |
0%; No deductible;
Service must be provided within 72 hours of injury; 20% thereafter to six months of accident |
| Dependent Child Age Limit |
End of the year they turn 26; unlimited if a full time single student or disabled before age 27 |
End of the year they turn 26; unlimited if a full time single student or disabled before age 27 |
End of the year they turn 26; unlimited if a full time single student or disabled before age 27 |
If you have questions or concerns regarding the enrollment
process, please contact: