Blue Advantage 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 Advantage 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 that are part of the Blue Advantage network. In Iowa City, this network includes Mercy Hospital and Mercy providers that participate in the network. With this plan, you must choose and receive routine care from a primary care provider that participates in the Blue Advantage network. Each female enrollee may also choose an OB/GYN care provider that participates in the network.
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. Referral required after 12 visits.
- 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 website 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
The 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. The 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 Advantage 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.
There is no out of pocket maximum for prescription drugs.
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 will choose a primary care provider. The individual and the provider will agree on the role residents will play in the individual's care. 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 Out of Network
The Blue Advantage Plan provides coverage for any Blue Advantage 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.