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Merit Health Insurance Benefit Comparison
Rates and Coverage - Effective January 1, 2014

(Download printable version)

Plan Provisions : Hospital Services : Miscellaneous : Mental, Nervous, and Substance Abuse

 

Plan Provisions

Wellmark Blue Access and Blue Advantage

BC/BS
Iowa Select

BC/BS
Program III Plus

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-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

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

 

Hospital Services

Wellmark Blue Access and Blue Advantage

BC/BS
Iowa Select

BC/BS
Program Three Plus

Room and Board

0%; Semi-private basis unless medically necessary to use a private room

Select: 10% after deductible;
Non-Select: 20% after deductible;

No limit on days; Semi-private basis unless medically necessary to use private room

20% after inpatient services deductible $300/$400;

No limit on days; Semi-private basis unless medically necessary to use private room

Physicians’ Services 0% if authorized

Select: deductible then 10%;
Non-Select: deductible then 20%

20% after deductible
Inpatient Surgery 0% if authorized

Select: deductible then 10%;

Non-Select: deductible then 20%

20% after deductible
Inpatient Supplies, Drugs, Medicines, Tests, ICU, OR, Specialized Care, etc. 0% if authorized

Select: deductible then 10%;

Non-Select: deductible then 20%

20% after deductible

 

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

 

Mental, Nervous, and Substance Abuse

Wellmark Blue Access and Blue Advantage

BC/BS
Iowa Select

BC/BS
Program Three Plus

Inpatient Hospital Room and Board

0%

Select: deductible then 10%;

Non-Select: deductible then 20%

20% after deductible

Inpatient Physician Care 0%

Select: deductible then 10%;

Non-Select: deductible then 20%

20% after deductible
Outpatient 0% co-payment 0% 0%
Pre-certification Required Required Required

 

Questions? Need Help?

If you have questions or concerns regarding the enrollment process, please contact:

University Benefits
120-40 USB

Email: benefits@uiowa.edu

Phone: 319-335-2676 or
877-830-4001 (toll free)

Fax: 319-335-2776

Page last updated 10/2013