Wellmark Blue Cross and Blue Shield

 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.

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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

Find a Doctor or Hospital

Annual

Medical Deductible -

you pay:
  Single
  Two-Person
  Family

$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%


40%
 

20%


40%
 

10%


30%

Annual

Out-of-Pocket Maximum -

you pay:
  Single
  Two-Person
  Family

$ 5,500
$11,000
$16,500

 $ 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

For Tier 1 or generic drugs -

you pay:

$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

For Tier 2 or specially selected brand name drugs -

you pay:

$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

For Tier 3 or all other brand name drugs -

you pay:

$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
50% major restorative

($1,000 Annual Maximum Benefit  Per Person)

Optional Coverage -

you pay: monthly rates

Oral

Contraceptives

$21.80
Apply for coverage

ESSENTIAL

 ENHANCED COMPREHENSIVE