Blue Access Plan
The Blue Access plan is a comprehensive health care program that covers hospital, medical, surgical, outpatient, and other health care services such as physical therapy. Coverage is also provided for routine physicals, newborn care (including inoculations, scheduled visits, etc.), well-child checkups, treatment of mental health conditions, treatment of chemical dependency, and prescription drugs.
How an Individual Uses the Blue Access Plan
Health care under this plan will be provided by physicians, advanced registered nurse practitioners, certified nurse midwives, and specialists at The University of Iowa Hospitals and Clinics, the University Community Medical Services Clinics, and community physicians and facilities who are part of the Wellmark Health Plan of Iowa network. In Iowa City, this network includes Mercy Hospital.
Care by non-participating providers needed due to medical necessity (examples: referrals or ambulance transportation) may involve higher cost to you. Non-participating providers do not have contracts with Blue Cross and Blue Shield. They do not agree to accept payment arrangements and are not responsible for filing claims for you. Non-participating providers may charge more for health care than participating providers. Payment is made to you and you are responsible for paying the provider. Non-participating providers can bill you for the difference between what Blue Cross and Blue Shield will pay for a service and what they charge (balance billing).
Referrals are needed for:
- Out-of-network providers – except for emergencies. Prior approvals are needed for all referrals outside the network.
- Chiropractic care in excess of 12 visits annually.
- Home/durable medical equipment, prosthetic appliances, and, if applicable, orthotics in excess of $1500 – Wellmark must approve the referral before the benefits are paid.
Who Can Be Covered
Coverage is provided through Wellmark Blue Cross & Blue Shield of Iowa. There are two contract options available: Employee Only, and Family
Coverage for children through the end of the calendar year in which they turn 26.
Domestic partners may also be covered on this policy. See the Domestic Partner Information on the Benefits Office web site for more information.
Dual University of Iowa employed spouses/partners and any children may not double insure each other or dependents under the plans where the University contributes towards the cost of the plans. This includes the health, dental, and AD&D insurance policies - an individual may only be included once under these policies.
How Much an Individual Pays for Health Care Services
Insureds will pay a $10 co-payment for routine office visits, an annual physical examination, well-child or normal newborn care, and routine eye and hearing exams. There is no co-pay for mental/nervous/substance abuse outpatient visits. There is no co-insurance on most services. Insureds will pay 20% co-insurance for durable medical equipment.
When an individual goes to an emergency room, the insured will pay a co-payment of $50 - this is waived if the individual is admitted to the hospital.
There is no charge for hospital room and board.
Out-of-Pocket Maximum (OPM) Expenses for Individuals and Families
The Blue Access Plan provides an annual maximum limit for the OPM expense for both individuals and families. The OPM for an individual's expenses is $750. The OPM for Family contracts is $1,500.
When the amount paid by the insured equals the applicable OPM, the plan pays 100% of the charges for most additional medically necessary expenses incurred during the remainder of the calendar year.
Amounts an insured pays as coinsurance are cumulated and determine the annual OPM expense. Co-payments do not apply toward meeting the OPM, and continue once the OPM is met.
Coverage for Prescription Drugs
This plan has a tiered prescription benefit. This means for each prescription you will pay a co-payment, which will vary depending on the tier (or category) of the drug.
The co-payment amounts are:
- Tier 1: $5 Wellmark generic formulary
- Tier 2: $15 Wellmark name brand formulary
- Tier 3: $30 or 25% whichever is higher, Wellmark non-formulary
You can search the Wellmark Drug List to determine which tier specific medications are in: http://www.wellmark.com/
The pharmacy is responsible for submitting your prescription claims electronically.
This plan also has a mail-order prescription provision that allows you to receive 3 months of a prescription medication while only paying 2 months of co-payments.
If you purchase a brand name drug when an FDA-approved “A”-rated generic equivalent is available, you are responsible for your co-payment or coinsurance, plus any difference between the billed charge for the brand name drug and the billed charge for the generic. This can result in you paying substantially higher costs than if you had chosen the generic drug.
Providers at The University of Iowa Hospitals and Clinics
When care is provided at The University of Iowa Hospitals and Clinics, the individual and the provider will agree on the role residents will play in the individual's care. An individual may choose to have all primary health care provided by faculty members. When an individual is hospitalized, residents and medical students are an integral part of the staff which provides support for treatment by the faculty.
Health Care for Individuals Who are Away from Iowa City
The Blue Access Plan provides coverage for any Blue Access network provider, and coverage for emergencies anywhere in the world. An emergency can be considered to be a medical condition that a prudent layperson (with an average knowledge of health and medicine) could reasonably expect to result in serious jeopardy to a person’s health in the absence of immediate medical attention. The emergency services must be provided in an emergency room setting.