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Wellmark Health Plan of Iowa, Inc.

The Wellmark Health Plan of Iowa, Inc. products are:

Primary Care Physicians (PCP) Referrals

Members covered by Blue Advantage and Blue Choice must choose a PCP (internist, family practitioner, or pediatrician) to manage their care.

• Blue Advantage: Members must receive services from their PCP or obtain referrals from their PCP before receiving services. The PCP is not required to submit notification of the referral to Wellmark except in certain situations (see below). Members may receive gynecological or obstetrical care from their selected OB/GYN without a referral.
• Blue Choice: Members are not required to receive referrals except in certain situations (see below).
• Blue Access: Members do not select a PCP. Consequently, they do not need a referral to receive benefits in most situations. However, a referral is required for out-of-network care (see below).

Referral Paperwork Requirements

Blue Advantage requires referral paperwork  for the following services to be considered for benefits:

• chiropractic visits after the twelfth visit each benefit period
• nonemergency out-of-network care, including transplants and laboratory services; nonemergency out-of-network care also requires Wellmark preapproval

Blue Choice requires referral paperwork  for the following services to be eligible for Level 2 benefits; otherwise, services will be eligible for Level 3 benefits, the highest level of member cost sharing:

• nonemergency out-of-network care, including transplants and laboratory services; nonemergency out-of-network care also requires Wellmark preapproval for Level 2 benefit consideration

Blue Access requires referral paperwork  for the following services to be considered for benefits:

• nonemergency out-of-network care, including transplants and laboratory services; nonemergency out-of-network care also requires Wellmark preapproval

Out-of-Network Laboratory Services

Remember, if you use an out-of-network laboratory for Wellmark Health Plan of Iowa members, you must seek and receive preapproval from Wellmark through the referral process. As with any other nonemergency out-of-network care, the member will experience full or higher liability for the services unless the approval is received beforehand.

Preventive Care Benefits and Requirements

Members with preventive care coverage must receive the care from the following providers to be eligible for benefits.

• Blue Advantage and Blue Choice members must receive preventive services from their PCP, their PCP’s backup clinician, or their selected OB/GYN.
• Blue Access members must receive preventive services from a PCP-type clinician (internist, family practitioner, or pediatrician).

These additional preventive benefits are available:

• Blue Advantage – A routine eye exam is payable when performed by a network optometrist or ophthalmologist.
• Blue Choice – A routine eye exam is payable at the highest benefit level (Level 1) when performed by a network optometrist or ophthalmologist. A routine gynecological exam is payable at the highest benefit level when performed by a network gynecologist. Other services by these two specialists process at Level 2.

To determine if a member’s contract includes coverage for preventive care, check our secure website at www.wellmark.com.

Out-of-Network Care

Members covered by Blue Advantage and Blue Access do not have benefits for out-of-network care unless services are a medical emergency or are preapproved through the referral process by Wellmark Health Plan of Iowa, Inc.

Blue Choice provides out-of-network benefits at a higher level (Level 2) when out-of-network services are pre-approved by Wellmark through the referral process. Otherwise, benefits process at Level 3. Whenever possible, in-network laboratory services should be used to keep member costs low.

Locating an In-Network Specialist for Referrals

1. Select Find a Doctor or Hospital from one of our home pages.
2. Select Doctors (Iowa, South Dakota, and bordering counties) link.
3. From the drop-down box, select the patient’s network. For patients covered by Wellmark Health Plan of Iowa, choose one of the following:

• Blue Access
• Blue Advantage
• Blue Choice
• hawk-i Blue Access

Additional Information

Access to Care Policies:

• After-Hours Nonemergency Care 
• Appointment Wait Time – Behavioral Health Care 
• Appointment Wait Time – Primary Medical/Surgical Care 

Health Management section, Wellmark Provider Guide: 

• Availability and Accessibility Standards
• Member Reminder Programs
• HEDIS^® Results
• NCQA Accreditation

Health Plan Ratings including HEDIS and NCQA information

Current Service Area Map