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Outline of Health Coverage

This is a general description of coverage. It is not a statement of contract. Actual coverage is subject to terms and conditions specified in the Benefits Certificate. Certain exclusions and limitations apply.

 

  Blue Access 500 PPO 500 PPO 1200 HDHP 2500
Lifetime Benefits Maximum
The maximum amount each covered family member is eligible to receive under this plan for covered services in his or her lifetime.

Lifetime benefits maximum amounts accumulate from claim payment amounts incurred from January 1, 2007, and thereafter under this any medical benefits plans sponsored by Hy-Vee Benefit Plan and administered by Wellmark Blue Cross and Blue Shield of Iowa or Wellmark Health Plan of Iowa, Inc.

 $1,500,000  $1,500,000  $1,500,000  $1,500,000
Lifetime Maximum on Infertility Services
 Does Not Apply
Out-of-Pocket Expenses

Out-of-Pocket Maximum
     Single PPO
     Family PPO

     Single Non-PPO
     Family Non-PPO


 $2,000
 $3,000

 $2,000
 $3,000


 $2,000
 $3,000

 $4,000
 $6,000
 $3,000
 $6,000

 $6,000
 $12,000
 $2,500
 $5,000

 $3,500
 $7,000

Benefit Period Deductible
     Single PPO
     Family PPO

     Single Non-PPO
     Family Non-PPO


 $500
 $1,500

 $500
 $1,500


 $500
 $1,500

 $1,000
 $3,000
 $1,200
 $3,600

 $2,400
 $7,200
 $2,500
 $5,000

$3,500
$7,000
Service Area Wellmark Health Plan of Iowa Alliance Select or Preferred-Care Blue Alliance Select or Preferred-Care Blue Alliance Select or Preferred-Care Blue
Coverage for Care Provided Outside of Iowa
BlueCard® PPO Program benefits apply. Learn how BlueCard works for your plan.

Out-of-Pocket Expenses for Covered Services

  • Preventive Services
  • Vision
  • Inpatient
  • Outpatient
  • Emergency Services
  • Chiropractic
  • Maternity Care
  • Mental Health
  • Specialty Drugs

    • Preventive Services

    When You Receive These Covered Services: You Pay:
     
    Blue Access 500
    PPO 500
    PPO 1200
    HDHP 2500
    Provider Type
    		 Wellmark Health Plan of Iowa Out of Network Select Non-Select Select Non-Select Select Non-Select
    Office Visit Services $20 copay Not covered $25 copay 40% after deductible 15% coinsurance 40% after deductible Applies to deductible Applies to deductible
    Adult Preventive Services
    Routine physical exams, well woman exams and covered related services (x-rays, lab work, immunizations).    		 $10 copay Not covered $10 copay 40% after deductible $10 copay 40% after deductible $25 copay Applies to deductible
    Mammograms (one per calendar year) $10 copay Not covered $10 copay 40% after deductible $10 copay 40% after deductible $25 copay Applies to deductible
    Well Child Care to Age 7, Well Child Immunizations $10 copay Not covered $10 copay 40% after deductible $10 copay 40% after deductible $25 copay Applies to deductible

    Vision

    When You Receive These Covered Services: You Pay:
     
    Blue Access 500
    PPO 500
    PPO 1200
    HDHP 2500
    Provider Type
    		 Wellmark Health Plan of Iowa Out of Network Select Non-Select Select Non-Select Select Non-Select
    Routine Vision Exam

    $20 copay

    Exam only

    		 Not covered

    $25 copay

    Exam only

    40% after deductible

    Exam only

    $25 copay

    Exam only

    40% after deductible

    Exam only

    Applies to deductible

    Exam only

    Applies to deductible

    Exam only
    Eyewear Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered

    Inpatient Services

    When You Receive These Covered Services: You Pay:
     
    Blue Access 500
    PPO 500
    PPO 1200
    HDHP 2500
    Provider Type
    		 Wellmark Health Plan of Iowa Out of Network Select Non-Select Select Non-Select Select Non-Select
    Inpatient Physician Services 10% after deductible Not covered 10% after deductible 40% after deductible 15% after deductible 40% after deductible Applies to deductible Applies to deductible
    Inpatient Hospital Services including Newborn Care and Maternity 10% after deductible Not covered 10% after deductible 40% after deductible 15% after deductible 40% after deductible Applies to deductible Applies to deductible

    Outpatient Services

    When You Receive These Covered Services: You Pay:
     
    Blue Access 500
    PPO 500
    PPO 1200
    HDHP 2500
    Provider Type
    		 Wellmark Health Plan of Iowa Out of Network Select Non-Select Select Non-Select Select Non-Select
    Outpatient Physician Services 10% after deductible Not covered 10% after deductible 40% after deductible 15% after deductible 40% after deductible Applies to deductible Applies to deductible
    Outpatient Hospital Services 10% after deductible Not covered 10% after deductible 40% after deductible 15% after deductible 40% after deductible Applies to deductible Applies to deductible

    Emergency Services

    When You Receive These Covered Services: You Pay:
     
    Blue Access 500
    PPO 500
    PPO 1200
    HDHP 2500
    Provider Type
    		 Wellmark Health Plan of Iowa Out of Network Select Non-Select Select Non-Select Select Non-Select
    Emergency Services: Urgent Care Facility 10% after deductible Not covered 10% after deductible 40% after deductible 15% after deductible 40% after deductible Applies to deductible Applies to deductible
    Emergency Services: Emergency Room $50 copay followed by deductible and 10% coinsurance Not covered $50 copay followed by deductible and 10% coinsurance $50 copay followed by deductible and 10% coinsurance $50 copay followed by deductible and 15% coinsurance 40% after deductible Applies to deductible Applies to deductible

    Chiropractic

    When You Receive These Covered Services: You Pay:
     
    Blue Access 500
    PPO 500
    PPO 1200
    HDHP 2500
    Provider Type
    		 Wellmark Health Plan of Iowa Out of Network Select Non-Select Select Non-Select Select Non-Select
    Chiropractic Care (Up to $300 per Benefit Period) $20 copay Not covered $25 copay 40% after deductible 15% after deductible 40% after deductible Applies to deductible Applies to deductible

    Maternity Care

    When You Receive These Covered Services: You Pay:
     
    Blue Access 500
    PPO 500
    PPO 1200
    HDHP 2500
    Provider Type
    		 Wellmark Health Plan of Iowa Out of Network Select Non-Select Select Non-Select Select Non-Select
    Maternity Care: Inpatient 10% after deductible Not covered 10% after deductible 40% after deductible 15% after deductible 40% after deductible Applies to deductible Applies to deductible
    Maternity Care: Outpatient 10% after deductible Not covered 10% after deductible 40% after deductible 15% after deductible 40% after deductible Applies to deductible Applies to deductible
    Maternity Care: Office Visits $20 copay Not covered $25 copay 40% after deductible 15% coinsurance 40% after deductible Applies to deductible Applies to deductible

    Mental Health

    When You Receive These Covered Services: You Pay:
     
    Blue Access 500
    PPO 500
    PPO 1200
    HDHP 2500
    Provider Type
    		 Wellmark Health Plan of Iowa Out of Network Select Non-Select Select Non-Select Select Non-Select
    Mental Health/Chemical Dependency Services:
    Inpatient - limited to 30 days per benefit period    		 10% after deductible Not covered 10% after deductible 40% after deductible 15% after deductible 40% after deductible Applies to deductible Applies to deductible
    Mental Health/Chemical Dependency Services:
    Outpatient/office - limited to 30 days per benefit period 120 per lifetime    		 $20 copay Not covered $25 copay 40% after deductible 15% coinsurance 40% after deductible Applies to deductible Applies to deductible

    Specialty Drugs

    When You Receive These Covered Services: You Pay:
     
    Blue Access 500
    PPO 500
    PPO 1200
    HDHP 2500
    Provider Type
    		 Wellmark Health Plan of Iowa Out of Network Select Non-Select Select Non-Select Select Non-Select
    Specialty Drugs $85 copay No benefits out of network $85 copay 50% coinsurance $85 copay 50% coinsurance Applies to deductible, then covered at 100% Applies to deductible, then covered at 100%
    		 
       
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