The following benefit summary is provided for Wellmark Blue Cross Blue Shield of Iowa. Please contact us Toll Free 1-866-775-9384 for an immediate quote or with any questions. |
Alliance Select Health Plans |
ESSENTIAL |
ENHANCED |
COMPREHENSIVE | ||||||||||
Deductible |
1500 |
2500 |
600 |
1200 |
1800 |
2400 |
3000 |
4200 | 300 | 750 | 1250 | 1750 | |
Type of Plan |
Preferred Provider Organization (PPO) |
||||||||||||
Provider Directory | |||||||||||||
Annual Medical Deductible - you pay: |
$1,500 $3,000 $4,500 |
$2,500 $5,000 $7,500 |
$600 $1,200 $1,800 |
$1,200 $2,400 $3,600 |
$1,800 $3,600 $5,400 |
$2,400 $4,800 $7,200 |
$3,000 $6,000 $9,000 |
$4,200 $8,400 $12,600 |
$300 $600 $900 |
$750 $1,500 $2,250 |
$1,250 $2,500 $3,750 |
$1,750 $3,500 $5,250 |
|
Coinsurance
you pay after deductible: Providers- Non Network Providers- |
20%
|
20%
|
10%
|
||||||||||
Annual Out-of-Pocket Maximum - you pay: |
$ 5,500 |
$
9,100 $18,200 $27,000 |
$1,600 $3,200 $4,800 |
$2,200 $4,400 $6,600 |
$2,800 $5,600 $8,400 |
$3,400 $6,800 $10,200 |
$4,000 $8,000 $12,000 |
$5,200 $10,400 $15,600 |
$1,300 $2,600 $3,900 |
$1,750 $3,500 $5,250 |
$2,250 $4,500 $6,750 |
$2,750 $5,500 $8,250 |
|
Lifetime Benefit Maximum |
$2,000,000 |
||||||||||||
Office Visit - you
pay: Providers |
$30 copayment; deductible waived | 20% coinsurance; deductible waived | 10% coinsurance; deductible waived | ||||||||||
Non Network Providers | Deductible; then 40% coinsurance | Deductible; then 40% coinsurance | Deductible; then 30% coinsurance | ||||||||||
Chiropractic Care | Not covered | Covered | Covered | ||||||||||
Routine Physical Exams | Not covered | Covered | Covered | ||||||||||
Well Child Care (up to age seven) | Not covered | Covered | Covered | ||||||||||
Maternity |
Complications only | Complications only | Covered | ||||||||||
Prescription Drugs Annual Deductible - you pay: |
BlueRx | BlueRx | BlueRx | ||||||||||
$500 | No separate deductible | $200, waived for Tier 1 or generic drugs | No separate deductible | ||||||||||
|
$10 or 25% of Wellmark's payment arrangement amount, whichever is greater | $15 or 25% of WellmarkÕs payment arrangement amount, whichever is greater | $15 or 25% of WellmarkÕs payment arrangement amount, whichever is greater | ||||||||||
|
$20 or 25% of Wellmark's payment arrangement amount, whichever is greater | $30 or 25% of WellmarkÕs payment arrangement amount, whichever is greater | $30 or 25% of WellmarkÕs payment arrangement amount, whichever is greater | ||||||||||
|
$20 or 25% of Wellmark's payment arrangement amount, whichever is greater | $45 or 25% of WellmarkÕs payment arrangement amount, whichever is greater | $45 or 25% of WellmarkÕs payment arrangement amount, whichever is greater | ||||||||||
Mental Health and Chemical Dependency | Not covered | Not Covered |
Covered (see policy limitations) |
||||||||||
Emergency Room Copayment | $75; waived if admitted |
No copayment | No copayment | ||||||||||
Out of State & Country
Coverage |
Covered by
Blue Card PPO; Present Wellmark Blue Cross Blue Shield ID card |
||||||||||||
Blue Dentalsm coinsurance you pay: |
20% diagnostic, preventive, basic restorative ($1,000 Annual Maximum Benefit Per Person) |
||||||||||||
Optional Coverage - you pay: monthly rates |
|
||||||||||||
Apply for coverage |
ESSENTIAL |
ENHANCED | COMPREHENSIVE |