STATE OF IOWA HEALTH INSURANCE PLAN COMPARISON EFFECTIVE JANUARY 1, 2016

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1 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 If there are discrepancies between this summary and Wellmark s benefit certificates, the certificates will govern in all cases. General Conditions of Coverage Benefits Available from Non- Participating 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. 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. Normal plan benefits for nonnetwork providers. Normal plan benefits. Coinsurance Percentage Not applicable unless noted below. 10% 20% 20% for all services Deductible None Single: $250 Single: $250 Single: $300 Family deductible is reached Family: $500 Family: $500 Family: $400 from amounts accumulated on behalf of any family member or Applies to both inpatient and Inpatient services only. combination of family members. outpatient services. Applies to both inpatient and outpatient services. Waived for services provided in office/clinic setting of select provider. The entire family deductible must be met before benefits payments are made. Dependent Child Age Limit 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. Medical Maximum Out-of- Pocket (MOP) Family maximum out-of-pocket is reached from amounts accumulated on behalf of any family member or combination of family members. Single: $750 Family: $1500 All copayments and coinsurance go toward out-of-pocket limit. Single: $650 Family: $1,450 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. Single: $650 Family: $1,450 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. Single: $650 Family: $1,450 All deductibles, coinsurance, and copayments go toward out-of-pocket limit. Lifetime Benefit Maximum None None None New Employee Preexisting No preexisting conditions No preexisting conditions No preexisting conditions Condition Waiting Period Revised 03/2016 Page 1

2 Monthly Premiums Single Coverage Note: Rates shown are 1/12 the annual cost $ $ $ Family Coverage 2 State Employees Coverage $1, $ $1, $ $1, Contract Holder $20 Contract Holder $ Contributing Spouse $0 Contributing Spouse $ Contract Holder $20 Contract Holder $ Contributing Spouse $0 Contributing Spouse $ Contract Holder $20 Contract Holder $ Contributing Spouse $0 Contributing Spouse $ UNI Employees Coverage $1, Professional Office Services $1, $1, Office Visit $10 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 Not covered Routine Hearing Exam Maternity Surgery, Radiology & Pathology (Office) *Limit of one exam per member per calendar year $10 copayment *Limit of one exam per member per calendar year 0% for delivery. $10 copayment for initial visit; remaining pre and postnatal visits paid in full *Limit one exam per member per year. *Limit one exam per member per year. 10%, deductible waived in office setting for pre and post-natal visits *Limit of one exam per member per calendar year Not covered *Limit of one exam per member per calendar year 20% after deductible 20%, no deductible for pre and post-natal office visits. $10 10%, deductible waived 20%, after deductible 20%, no deductible Revised 03/2016 Page 2

3 Hospital Services Inpatient Hospital Services Preapproval of Inpatient Admission Inpatient Hospital Services Room & Board Inpatient Physician Services Inpatient Supplies Inpatient Surgery Outpatient Hospital Services STATE OF IOWA HEALTH INSURANCE PLAN COMPARISON Required Required Required Required 10% 10%, after deductible 20%, after deductible 20%, after deductible Ambulatory Surgical Center 10% 10%, after deductible 20%, after deductible 20%, no deductible Outpatient Diagnostic Lab, Radiology Emergency Care 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. Behavioral Health Services Inpatient Mental Health and Substance Abuse Treatment Outpatient Mental Health and Substance Abuse Treatment Outpatient Therapy Services Chemotherapy Physical Therapy Occupational Therapy Respiratory Therapy Speech Therapy 20%, after deductible 0%, no deductible 10% 10%, after deductible 20%, after deductible 20%, after deductible 10% $0 copayment $0 copayment $0 copayment $10 copayment per visit 60 visit limit for each of the following services: Physical Therapy (excluding Chiropractic) Occupational Therapy Respiratory Therapy Speech Therapy 10%, after deductible 20%, after deductible 20%, no deductible Revised 03/2016 Page 3

4 Prescription Drug Coverage Retail Quantity Tier 1 Medications Tier 2 Medications Tier 3 Medications STATE OF IOWA HEALTH INSURANCE PLAN COMPARISON maintenance and non-maintenance $5 copayment for a 30-day supply or for a 90-day supply per for a 30-day supply or $45 copayment for a 90-day supply per $30 copayment or 25%, whichever is greater, for a 30-day supply per. $90 copayment or 25%, whichever is greater, for a 90-day supply per Wellmark Drug List for all Plans (Select Blue Rx Complete) maintenance and nonmaintenance $5 copayment for a 30-day supply or for a for a 30-day supply or $45 copayment for a $30 copayment for a 30-day supply per. $90 copayment for a 90-day supply per maintenance and nonmaintenance $5 copayment for a 30-day supply or for a for a 30-day supply or $45 copayment for a $30 copayment for a 30-day supply per. $90 copayment for a 90-day supply per maintenance and nonmaintenance $5 copayment for a 30-day supply or for a for a 30-day supply or $45 copayment for a $30 copayment for a 30-day supply per. $90 copayment for a 90-day supply per 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 up to a 90 day supply $10 copayment for each $10 copayment for each $10 copayment for each Tier 2 Medications Tier 3 Medications Tier 4 Medications $30 copayment for each prescription up to a 90 day supply prescription up to a 90 day supply prescription up to a 90 day supply $30 copayment for each $30 copayment for each $30 copayment for each Pharmacy Out-of-Pocket Maximum Single $5,850 Family $11,700 Family out-of-pocket is reached from amounts accumulated on behalf of any family member or combination of family members. Single $500 Family $1,000 Family out-of-pocket is reached from amounts accumulated on behalf of any family member or combination of family members. Single $500 Family $1,000 Family out-of-pocket is reached from amounts accumulated on behalf of any family member or combination of family members. Single $500 Family $1,000 Family out-of-pocket is reached from amounts accumulated on behalf of any family member or combination of family members. Revised 03/2016 Page 4

5 Glossary of Benefit Terms 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 Copayment A fixed amount you pay for a Copayment A fixed amount you pay for a covered Copayment covered health care service, usually health care service, usually when you when you receive the service. receive the service. In-Network Tier 4 Limited-value Max out-of-pocket (MOP) Providers who contract with your health plan. Your payments may be less when seeking treatment from an in-network facility or physician. Limited-value are combination products, lifestyle, or with more costeffective options available on lower tiers (i.e. generics) 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. In-Network Tier 4 Limitedvalue Max out-of-pocket (MOP) Providers who contract with your health plan. Your payments may be less when seeking treatment from an in-network facility or physician. Limited-value are combination products, lifestyle, or with more cost-effective options available on lower tiers (i.e. generics) 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. Note: Emergency Room copayment continues to apply after out-of-pocket limit is met. In-Network Tier 4 Limitedvalue Max out-of-pocket (MOP) The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. A fixed amount you pay for a covered health care service, usually when you receive the service. Not Applicable Limited-value are combination products, lifestyle, or with more costeffective options available on lower tiers (i.e. generics) 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. Single $750 Medical MOP $5,850 Rx MOP $6,600 Total MOP Family $1,500 Medical MOP $11,700 Rx MOP $13,200 Total MOP Single $650 Medical MOP $500 Rx MOP $1,150 Total MOP Family $1,450 Medical MOP $1,000 Rx MOP $2,450 Total MOP Single $650 Medical MOP $500 Rx MOP $1,150 Total MOP Family $1,450 Medical MOP $1,000 Rx MOP $2,450 Total MOP Revised 03/2016 Page 5

6 Revised 03/2016 Page 6