STATE OF IOWA HEALTH INSURANCE PLAN COMPARISON
EFFECTIVE JANUARY 1, 2016
This comparison is only a summary of benefits. Benefits will be administered as described in each plan’s Summary of Benefits & Coverage. For
further details, refer to those documents or call Wellmark Blue Cross Blue Shield at 1-800-622-0043. If there are discrepancies between this
summary and Wellmark’s benefit certificates, the certificates will govern in all cases.
Managed Care Plans
PPO Plans
Indemnity Plan
Blue Access
Iowa Select
Program 3 Plus
In Network
Out-of-Network
(Select Provider)
(Non-Select Provider)
General Conditions of Coverage
Benefits Available from NonParticipating Providers
You are responsible for any
amounts between the billed
charge and the maximum
allowable fee paid by Wellmark.
These amounts will not
accumulate towards the medical
out-of pocket maximum.
Coinsurance Percentage
None, unless prescribed and referred
by a participating physician and
approved by Wellmark, or in an
emergency medical situation.
Normal plan benefits for
network providers.
Deductible
Family deductible is reached
from amounts accumulated on
behalf of any family member or
combination of family members.
Not applicable unless noted below.
10%
20%
20% for all services
None
Single: $250
Family: $500
Single: $250
Family: $500
Single: $300
Family: $400
Applies to both inpatient and
outpatient services. Waived for
services provided in office/clinic
setting of select provider.
Applies to both inpatient and
outpatient services.
Inpatient services only.
Normal plan benefits for nonnetwork providers.
Normal plan benefits.
The entire family deductible
must be met before benefits
payments are made.
Dependent Child Age Limit
•
•
•
Medical Maximum Out-ofPocket (MOP)
Single: $750
Family: $1500
Single: $650
Family: $1,450
Single: $650
Family: $1,450
Single: $650
Family: $1,450
Family maximum out-of-pocket
is reached from amounts
accumulated on behalf of any
family member or combination
of family members.
All copayments and coinsurance go
toward out-of-pocket limit.
Applies to services provided
both in- and out-of-network. All
deductibles, coinsurance, and
copayments go toward out-ofpocket limit. Emergency Room
copayment continues to apply
after out-of-pocket limit is met.
Applies to services provided
both in- and out-of-network. All
deductibles, coinsurance, and
copayments go toward out-ofpocket limit. Emergency Room
copayment continues to apply
after out-of-pocket limit is met.
All deductibles, coinsurance,
and copayments go toward
out-of-pocket limit.
Lifetime Benefit Maximum
None
None
None
New Employee Preexisting
Condition Waiting Period
No preexisting conditions
No preexisting conditions
No preexisting conditions
Children through the end of the year in which they turn age 26 regardless of marital status or residency.
Unmarried children over the age of 26 who are full-time students in an accredited institution of post secondary education.
Unmarried children who are totally and permanently disabled, physically or mentally, regardless of age. The disability must have existed
before the child turned age 27 or while a full-time student.
Revised 03/2016
Page 1
NOTE: The Wellmark Blue Cross and Blue Shield (BCBS) plan’s coverage percentage for hospital and other facility services does not reflect the actual payment to the provider. The actual payment to the provider is based on BCBS’s contract with the provider. The percentage is used
in this document for comparison purposes only. On any given claim, the amount represented by the coverage percentage times the covered charge may be satisfied by BCBS’s payment to the provider plus any amounts the provider agrees to waive under its contract with BCBS.
Please see your coverage manual for more information.
STATE OF IOWA HEALTH INSURANCE PLAN COMPARISON
EFFECTIVE JANUARY 1, 2016
Managed Care Plans
PPO Plans
Indemnity Plan
Blue Access
Iowa Select
Program 3 Plus
In Network
Out-of-Network
(Select Provider)
(Non-Select Provider)
Monthly Premiums
Note: Rates shown are 1/12 the annual cost
Single Coverage
 Employee’s Contribution
 UNI’s Contribution
$20.00
$601.10
$20.00
$829.04
$20.00
$831.66
$20.00
$1,435.20
$297.92
$1,690.77
$304.04
$1,690.77
Contract Holder $20
Contract Holder $707.60
Contributing Spouse $0
Contributing Spouse $727.60
Contract Holder $20
Contract Holder $974.35
Contributing Spouse $0
Contributing Spouse $994.35
Contract Holder $20
Contract Holder $977.41
Contributing Spouse $0
Contributing Spouse $997.41
$20.00
$1,435.20
$20.00
$1,968.69
$20.00
$1,974.81
Family Coverage
 Employee’s Contribution
 UNI’s Contribution
2 State Employees
Coverage
 Employee’s Contribution
 UNI’s Contribution
 Employee’s Contribution
 UNI’s Contribution
2 UNI Employees
Coverage
 Employee’s Contribution
 UNI’s Contribution
Professional Office Services
Office Visit
$10 copayment
$15 copayment
$15 copayment
$15 copayment
Allergy Testing
$10 copayment
10%, deductible waived
20%, after deductible
20%, no deductible
Allergy Serum and Injections
$10 copayment
10%, deductible waived
20%, after deductible
20%, no deductible
Chiropractor
$10 copayment, if approved
10%, deductible waived
20%, after deductible
20%, no deductible
Routine Eye Exam
$10 copayment
$15 copayment
$15 copayment
Not covered
*Limit of one exam per member per
calendar year
*Limit one exam per member
per year.
*Limit of one exam per member
per calendar year
$10 copayment
$15 copayment
$15 copayment
*Limit of one exam per member per
calendar year
*Limit one exam per member
per year.
*Limit of one exam per member
per calendar year
Maternity
0% for delivery. $10 copayment for
initial visit; remaining pre and postnatal visits paid in full
10%, deductible waived in office
setting for pre and post-natal
visits
20% after deductible
20%, no deductible for pre and
post-natal office visits.
Surgery, Radiology & Pathology
(Office)
$10
10%, deductible waived
20%, after deductible
20%, no deductible
Routine Hearing Exam
Not covered
Revised 03/2016
Page 2
NOTE: The Wellmark Blue Cross and Blue Shield (BCBS) plan’s coverage percentage for hospital and other facility services does not reflect the actual payment to the provider. The actual payment to the provider is based on BCBS’s contract with the provider. The percentage is used
in this document for comparison purposes only. On any given claim, the amount represented by the coverage percentage times the covered charge may be satisfied by BCBS’s payment to the provider plus any amounts the provider agrees to waive under its contract with BCBS.
Please see your coverage manual for more information.
STATE OF IOWA HEALTH INSURANCE PLAN COMPARISON
EFFECTIVE JANUARY 1, 2016
Managed Care Plans
PPO Plans
Indemnity Plan
Blue Access
Iowa Select
Program 3 Plus
In Network
Out-of-Network
(Select Provider)
(Non-Select Provider)
Hospital Services
Inpatient Hospital Services
Preapproval of Inpatient
Admission
Required
Required
Required
Required
Inpatient Hospital Services
10%
10%, after deductible
20%, after deductible
20%, after deductible
•
Room & Board
•
Inpatient Physician
Services
•
Inpatient Supplies
•
Inpatient Surgery
Outpatient Hospital Services
Ambulatory Surgical Center
10%
10%, after deductible
20%, after deductible
20%, no deductible
Outpatient Diagnostic Lab,
Radiology
10%
10%, deductible waived
20%, after deductible
20%, no deductible
Ambulance
10%
20, after deductible
20%, after deductible
20%, no deductible
Urgent Care Center
10%
10%, after deductible
20%, after deductible
20%, after deductible
Hospital Emergency Room
$50 copayment; waived if admitted
$50 copayment; waived if
admitted.
20%, after deductible
0%, no deductible
Emergency Care
Behavioral Health Services
Inpatient Mental Health and
Substance Abuse Treatment
10%
10%, after deductible
20%, after deductible
20%, after deductible
Outpatient Mental Health and
Substance Abuse Treatment
10%
$0 copayment
$0 copayment
$0 copayment
10%, after deductible
20%, after deductible
20%, no deductible
Outpatient Therapy Services
•
Chemotherapy
•
Physical Therapy
•
Occupational Therapy
•
Respiratory Therapy
•
Speech Therapy
$10 copayment per visit
60 visit limit for each of the following
services:
Physical Therapy (excluding Chiropractic)
Occupational Therapy
Respiratory Therapy
Speech Therapy
Revised 03/2016
Page 3
NOTE: The Wellmark Blue Cross and Blue Shield (BCBS) plan’s coverage percentage for hospital and other facility services does not reflect the actual payment to the provider. The actual payment to the provider is based on BCBS’s contract with the provider. The percentage is used
in this document for comparison purposes only. On any given claim, the amount represented by the coverage percentage times the covered charge may be satisfied by BCBS’s payment to the provider plus any amounts the provider agrees to waive under its contract with BCBS.
Please see your coverage manual for more information.
STATE OF IOWA HEALTH INSURANCE PLAN COMPARISON
EFFECTIVE JANUARY 1, 2016
Managed Care Plans
PPO Plans
Indemnity Plan
Blue Access
Iowa Select
Program 3 Plus
Prescription Drug Coverage
In Network
Out-of-Network
(Select Provider)
(Non-Select Provider)
Wellmark Drug List for all Plans http://www.wellmark.com (Select ‘Blue Rx Complete)
Retail
Quantity
30-day or 90-day supply for
maintenance and non-maintenance
drugs
30-day or 90-day supply for
maintenance and nonmaintenance drugs
30-day or 90-day supply for
maintenance and nonmaintenance drugs
30-day or 90-day supply for
maintenance and nonmaintenance drugs
Tier 1 Medications
$5 copayment for a 30-day supply or
$15 copayment for a 90-day supply
per prescription or refill
$5 copayment for a 30-day
supply or $15 copayment for a
90-day supply per prescription
or refill
$5 copayment for a 30-day
supply or $15 copayment for a
90-day supply per prescription
or refill
$5 copayment for a 30-day
supply or $15 copayment for a
90-day supply per prescription
or refill
Tier 2 Medications
$15 copayment for a 30-day supply or
$45 copayment for a 90-day supply
per prescription or refill
$15 copayment for a 30-day
supply or $45 copayment for a
90-day supply per prescription
or refill
$15 copayment for a 30-day
supply or $45 copayment for a
90-day supply per prescription
or refill
$15 copayment for a 30-day
supply or $45 copayment for a
90-day supply per prescription
or refill
Tier 3 Medications
$30 copayment or 25%, whichever is
greater, for a 30-day supply per
prescription or refill. $90 copayment
or 25%, whichever is greater, for a
90-day supply per prescription or refill
$30 copayment for a 30-day
supply per prescription or refill.
$90 copayment for a 90-day
supply per prescription or refill
$30 copayment for a 30-day
supply per prescription or refill.
$90 copayment for a 90-day
supply per prescription or refill
$30 copayment for a 30-day
supply per prescription or refill.
$90 copayment for a 90-day
supply per prescription or refill
Tier 4 Medications
Same as Tier 3
Same as Tier 3
Same as Tier 3
Same as Tier 3
Mail Order Prescription Drugs
Tier 1 Medications
$10 copayment for each prescription
or refill up to a 90 day supply
$10 copayment for each
prescription or refill
$10 copayment for each
prescription or refill
$10 copayment for each
prescription or refill
Tier 2 Medications
$30 copayment for each prescription
or refill up to a 90 day supply
$30 copayment for each
prescription or refill
$30 copayment for each
prescription or refill
$30 copayment for each
prescription or refill
Tier 3 Medications
$60 copayment for each prescription
or refill up to a 90 day supply
$60 copayment for each
prescription or refill
$60 copayment for each
prescription or refill
$60 copayment for each
prescription or refill
Tier 4 Medications
$60 copayment for each prescription
or refill up to a 90 day supply
$60 copayment for each
prescription or refill
$60 copayment for each
prescription or refill
$60 copayment for each
prescription or refill
Single $5,850
Single $500
Single $500
Single $500
Family $11,700
Family $1,000
Family $1,000
Family $1,000
Family out-of-pocket is reached from
amounts accumulated on behalf of
any family member or combination of
family members.
Family out-of-pocket is reached
from amounts accumulated on
behalf of any family member or
combination of family members.
Family out-of-pocket is reached
from amounts accumulated on
behalf of any family member or
combination of family members.
Family out-of-pocket is
reached from amounts
accumulated on behalf of any
family member or combination
of family members.
Pharmacy Out-of-Pocket Maximum
Revised 03/2016
Page 4
NOTE: The Wellmark Blue Cross and Blue Shield (BCBS) plan’s coverage percentage for hospital and other facility services does not reflect the actual payment to the provider. The actual payment to the provider is based on BCBS’s contract with the provider. The percentage is used
in this document for comparison purposes only. On any given claim, the amount represented by the coverage percentage times the covered charge may be satisfied by BCBS’s payment to the provider plus any amounts the provider agrees to waive under its contract with BCBS.
Please see your coverage manual for more information.
STATE OF IOWA HEALTH INSURANCE PLAN COMPARISON
EFFECTIVE JANUARY 1, 2016
Glossary of Benefit Terms
Blue Access
Iowa Select
Program 3 Plus
Deductible
Not Applicable
Deductible
The amount you owe for health care
services your health insurance or plan
covers before your health insurance or
plan begins to pay.
Deductible
The amount you owe for health care
services your health insurance or
plan covers before your health
insurance or plan begins to pay.
Copayment
A fixed amount you pay for a
covered health care service, usually
when you receive the service.
Copayment
A fixed amount you pay for a covered
health care service, usually when you
receive the service.
Copayment
A fixed amount you pay for a
covered health care service, usually
when you receive the service.
In-Network
Providers who contract with your
health plan. Your payments may be
less when seeking treatment from
an in-network facility or physician.
In-Network
Providers who contract with your health
plan. Your payments may be less when
seeking treatment from an in-network
facility or physician.
In-Network
Not Applicable
Tier 4 Limited-value
drugs
Limited-value drugs are
combination products, lifestyle
drugs, or drugs with more costeffective options available on lower
tiers (i.e. generics)
Tier 4 Limitedvalue drugs
Limited-value drugs are combination
products, lifestyle drugs, or drugs with
more cost-effective options available on
lower tiers (i.e. generics)
Tier 4 Limitedvalue drugs
Limited-value drugs are
combination products, lifestyle
drugs, or drugs with more costeffective options available on lower
tiers (i.e. generics)
Max out-of-pocket (MOP)
This is the most you could pay
during a coverage period (usually
one calendar year) for your share of
the cost of covered services. This
limit helps you plan for health care
expenses.
Max out-of-pocket
(MOP)
This is the most you could pay during a
coverage period (usually one calendar
year) for your share of the cost of covered
services. This limit helps you plan for
health care expenses. The in-network
health and drug card maximum out of
pocket amounts accumulate separately.
Max out-of-pocket
(MOP)
This is the most you could pay
during a coverage period (usually
one year) for your share of the cost
of covered services. This limit helps
you plan for health care expenses.
Note: Emergency Room copayment
continues to apply after out-of-pocket limit
is met.
Single
Single
Single
$750 Medical MOP
$650 Medical MOP
$650 Medical MOP
$5,850 Rx MOP
$500 Rx MOP
$500 Rx MOP
$6,600 Total MOP
$1,150 Total MOP
$1,150 Total MOP
Family
$1,500 Medical MOP
Family
$1,450 Medical MOP
Family
$1,450 Medical MOP
$11,700 Rx MOP
$1,000 Rx MOP
$1,000 Rx MOP
$13,200 Total MOP
$2,450 Total MOP
$2,450 Total MOP
Revised 03/2016
Page 5
NOTE: The Wellmark Blue Cross and Blue Shield (BCBS) plan’s coverage percentage for hospital and other facility services does not reflect the actual payment to the provider. The actual payment to the provider is based on BCBS’s contract with the provider. The percentage is used
in this document for comparison purposes only. On any given claim, the amount represented by the coverage percentage times the covered charge may be satisfied by BCBS’s payment to the provider plus any amounts the provider agrees to waive under its contract with BCBS.
Please see your coverage manual for more information.
STATE OF IOWA HEALTH INSURANCE PLAN COMPARISON
EFFECTIVE JANUARY 1, 2016
Revised 03/2016
Page 6
NOTE: The Wellmark Blue Cross and Blue Shield (BCBS) plan’s coverage percentage for hospital and other facility services does not reflect the actual payment to the provider. The actual payment to the provider is based on BCBS’s contract with the provider. The percentage is used
in this document for comparison purposes only. On any given claim, the amount represented by the coverage percentage times the covered charge may be satisfied by BCBS’s payment to the provider plus any amounts the provider agrees to waive under its contract with BCBS.
Please see your coverage manual for more information.