DRAKE UNIVERSITY HEALTH PLAN Effective Date: 1/1/2015 This is a general description of coverage. It is not a statement of contract. Actual coverage is subject to terms and the conditions specified in the summary plan description you will receive after you enroll, including the enrollment regulations in force when the plan document is effective. Certain exclusions and limitations apply. MEDICAL BENEFITS PATIENT S LIABILITY Medical Deductible: (per calendar year) - Per Individual - Per Family $850 $1700 $2500 $5000 No fourth quarter carryover. The deductible is waived when an Office Services Co-Pay is taken. The In Network and Out of Network deductibles are mutually exclusive. Out-of-Pocket Maximums: (per calendar year) - Per Individual - Per Family $2000 $4000 $4000 $8000 Includes Calendar Year Deductibles, Co-Pays and Coinsurance amounts. Excludes Hospital Preadmission Certification Penalty, Adult Vision hardware, and Prescription Drug Program Co-Pays. The In and Out of Network out-of-pocket maximums are mutually exclusive. Office Services Co-Pay** $25 / visit $50/ visit Co-Pay applies with or without office visit charges. Co-Pay is waived for Preventive Care services and Well- Baby/Well-Child Care. After Out of Network Co-Pay, Out of - Network services may be subject to balance billing. ** Except: Anesthesia; Cardiac Rehabilitations; Chemotherapy; Interpretations (which are separate from an office visit); Occupational Therapy; Physical Therapy; Radiation Therapy; Respiratory/Inhalation Therapy; Speech Therapy; Preventive Care Benefits (Routine and Well-child Care) NOTES: Your Drake University health plan allows you to receive care from any health care provider you choose, but when you choose a health care provider who participates with the Alliance Select network, you reduce your out-of-pocket expenses. To find an in-network health care provider, visit www.wellmark.com or call the Customer Service number on your ID card. Preadmission Certification: Precertification helps determine whether a service or admission to a facility is medically necessary. Precertification is required; however, it does not apply to maternity or emergency services. For a complete list of services requiring precertification, visit Wellmark.com. In-network providers in the states of Iowa and South Dakota and Blue Card Providers outside Iowa and South Dakota obtain precertification for you. However, you or someone acting on your behalf are responsible for notifying us if: You are admitted to a facility outside Iowa or South Dakota and they are not a BlueCard Provider. You receive any of the services requiring precertification from an out-of-network provider. Failure to comply with the Hospital Preadmission Certification provision will result in a $500 penalty applied to hospital related inpatient charges. Customer service hours Mon Fri 7:30 am to 5:00 pm 1-800-524-9242
Allergy Exam Includes injections, testing, and serum. Injections covered at 10 if the purpose of the office visit is for an injection only. Injections/Testing/Serum Ambulance Benefits Limited to local air or ground. Ambulatory/Outpatient Surgery Facility Care Anesthesia Includes anesthesia administered by a CRNA. Cardiac Rehabilitation Limited to phase I (inpatient) and phase II (outpatient) treatment only; phase III treatment (diet, exercise, healthy lifestyle programs) is excluded. Chiropractic Services (Manual/Mechanical Manipulation of Spinal Column) Consultations Office Includes Manipulation, x-rays, and office visits. Inpatient/Outpatient Contraceptive Management Benefits Includes injectable contraceptives (e.g., Depo-Provera), implantable contraceptives (e.g., Norplant), contraceptive device (e.g., IUD), and surgical removal of contraceptives. Dental Services and Oral Surgery Covered Under the Medical Plan Limited to 18-month treatment period provided initial treatment is begun within 6 months of the injury. Diagnostic X-ray & Laboratory Benefits Durable Medical Equipment Rental limited to purchase price Emergency Room In-Network deductible and In-Network Out-of-Pocket will apply to Non-Network services.
Hearing Exam (Routine-office) $50 Co-pay or Limited to one per benefit year Home Health Care Services Prior approval is recommended. Limited to 100 visits per calendar year. Home Infusion Prior approval is recommended. Hospice Care - Inpatient -Respite Hospital Benefits Infertility - Prior approval is recommended. Subject to Case Management approval. Limited to employee, covered spouse or covered domestic partner. Artificial insemination, IVF, GIFT, ZIFT and other transfer procedures are covered up to a lifetime maximum of $20,000 does not apply to OPM. Inpatient Newborn Care Deductible waived for newborn care- coinsurance applied to Individual OPM Maternity Benefits (applies to mother only) Payable for all female participants. Office Services Co-Pay will apply for the OB global physician s fee. -Outpatient/Inpatient Deductible waived - coinsurance applied to Individual OPM Mental Health and Chemical Dependency Benefits Morbid Obesity Excludes weight loss classes. Bariatric Surgery Prior approval required. Nursing Facility Benefits Limited to 120 days per illness or injury. Nutritional Counseling- Office Outpatient /Inpatient Physician Services Up to 3 visits per year In Network providers first 3 visits paid at 10 - then subject to $25 co-pay, deductible and coinsurance.
Prescription Drugs Includes only those allowable drugs, medications and supplies that are not payable under the Prescription Drug Card. Preventive Care Services up to $500 Then subject to$50 Co-pay or For out of network limited to $500 per calendar year for participants age 7 and older. Eligible charges exceeding $500 will be subject to the Office Services Co-Pay, Deductible and Coinsurance. There is no limit on the benefits paid for Preventive Services in excess of $500. Includes all claims submitted with a routine diagnosis including but not limited to: - physical exam - mammogram - routine x-ray/lab - immunizations - cancer screenings - prostate screenings - pap smears - office visits for contraceptive management NOTE: Benefits for ACA mandated services are payable at 10 when a Network provider is used. If a Non-Network provider is used the benefit will revert to the Preventive Care Services benefit subject to the limitations. Private Duty Nursing Prosthetic Devices Radiation Therapy and Chemotherapy Surgical Benefits Therapy Benefits (Respiratory/Inhalation, Occupation, Speech, and Physical Therapy) Excludes occupational therapy supplies. Limited to 60 visits for each therapy per calendar year. Prior approval is required for additional visits. Transplant Benefits - Meals/Lodging/Travel Includes heart, heart/lung, liver, pancreas, kidney, bone marrow and cornea. Limited to $10,000 per transplant. Travel, meals, and lodging for the recipient and a companion will be covered if the transplant facility is more than 100 miles from the recipient s home. This benefit does not include ambulance expenses for the covered recipient.
Vision Exam Routine $50 Co-pay Limited to one per benefit year. Vision Hardware Adult The calendar year deductible is waived. Participant coinsurance amounts do not apply to the out-of-pocket maximum. Limited to $150 per calendar year. Includes eyeglass frames, lenses, and contact lenses. NOTE: Charges will not be subject to the network fee schedule and the participant will be responsible for the difference between the billed amount and the paid amount for frames, lenses, and contact lenses. Vision Hardware Pediatric Well-Baby/Well-Child Care (up to age 7) up to $150 up to $150 The calendar year deductible is waived. Participant coinsurance amounts do apply to the out-of-pocket maximum. Covered at 10 up to $150 per calendar year, then coinsurance applies. Includes eyeglass frames, lenses, and contact lenses. NOTE: Charges will not be subject to the network fee schedule and the participant will be responsible for the difference between the billed amount and the paid amount for frames, lenses, and contact lenses. Office Services Co-Pay and Deductible is waived. Includes all claims submitted with a routine diagnosis including but not limited to: routine exams, routine labs/x-rays, immunizations, and one eye exam per calendar year.
PRESCRIPTION DRUG CARD PROGRAM BENEFITS PRESCRIPTION DRUG BENEFITS PATIENT S LIABILITY Blue Rx Complete - Tier 1 (Most Generics) - 30-day supply - 60-day supply - 90-day supply - Tier 2,3,4 (Most Brand) - 30-day supply - 60-day supply - 90-day supply $7 Co-Pay $14 Co-Pay $21 Co-Pay the lesser of 4 or $75 the lesser of 4 or $150 the lesser of 4 or $225 NOTE: Includes smoking cessation products including overthe-counter which requires a prescription. Maintenance drugs can be purchased in a 60-day or 90-day supply at retail pharmacies. Maintenance drugs can be purchased in a 90-day supply through the mail order pharmacy program. Out-of-Pocket Maximum (OPM) separate from Health: Single out-of-pocket maximum is $ 2500 Family out-of-pocket maximum is $ 5000 Please refer to Plan Document for PRESCRIPTION PLAN INCLUSIONS and EXCLUSIONS To view covered prescription drugs go to www.wellmark.com When selecting a drug list use Blue Rx Complete Some medications may have additional requirements or limits on coverage. The Wellmark Drug List indicates pharmacy programs that may apply to the prescription drug. PRIOR AUTHORIZATION (PA) indicates a drug requires prior authorization before it is covered under your benefits. Prior authorization helps ensure a drug is medically necessary and part of a specific treatment plan. If you are currently taking or are prescribed a medication that requires prior authorization, your doctor will need to submit a prior authorization request to be considered for coverage. If Wellmark authorizes the drug, you can fill your prescription at any participating pharmacy. Without prior authorization, the medication will not be covered. Information about prior authorization and steps on how to obtain a prior authorization approval can be found on Wellmark.com. QUANITY LIMITS S (QL) - indicates there is a maximum quantity per month for a medication or supply. Quantity limitations are based on the Food and Drug Administration guidelines and the manufacturer s dosing recommendations. If you need to take a drug more often than what is allowed, your doctor can make a special request for coverage. Steps for obtaining this authorization are on Wellmark.com. SPECIALITY DRUGS (SP) - are high-cost drugs used to treat complex or rare conditions, which generally require close supervision and monitoring of patient therapy. Wellmark has arrangements with preferred Specialty Pharmacies to help you get any specialty medications you may need to manage a unique health condition. STEP THERAPY - Step therapy requires trying other therapeutically equivalent drug options first. When the pharmacist files the claim, the computer system searches the prescription claim history to determine if a therapeutically equivalent option has been tried. If a claim is found, the prescription is approved. If a claim is not found, the pharmacist will be asked to contact the physician. The physician can either prescribe a therapeutically equivalent option or contact the Wellmark Clinical Call Center for a prior authorization. See your plan documents for details on how these pharmacy programs apply to your plan.