Know Your Benefits

Blue Advantage^® – What You Need to Know

See your primary care provider (PCP)

Each person in your family selects a PCP from our list of general/family practice physicians, internists, and pediatricians that are part of the Wellmark Health Plan of Iowa* network. Your PCP provides your care or refers you to a network specialist when necessary.

In addition to choosing a PCP, female members can also designate a network obstetrician/gynecologist (OB/GYN). Benefits for preventive care services are only available when you see your designated PCP or OB/GYN.

Changing your provider

You can change your PCP or OB/GYN at any time by calling customer service. The change takes effect the first of the month following your request.

Use network providers

To receive benefits, you must:

• Receive services from health care providers that are part of the Wellmark Health Plan of Iowa network.
  
  
• Verify that your PCP or specialist uses only network providers for all covered services. This includes, but is not limited to:

Laboratory services

Radiology interpretations

Durable medical equipment

Notify Wellmark of referrals when necessary

In the following situations your provider is required to notify Wellmark Health Plan of Iowa of a referral to assure you receive benefits:

• Chiropractic care. PCP notifies Wellmark of referrals for chiropractic care beyond the first 12 visits. Wellmark must be notified of the referral before benefits are allowed.



• Home/durable medical equipment, prosthetic appliances, and, if applicable, orthotics in excess of $250. Wellmark Health Plan of Iowa providers notifies Wellmark of referrals for the rental or purchase of home/durable medical equipment. Wellmark must be notified of the referral before benefits are allowed.



• Out-of-network providers. On those rare occasions when the required care is beyond the scope of services available through a network provider, the PCP must notify Wellmark of referrals to any provider outside the network. The referral must be approved by Wellmark prior to receiving services.
  

Pay your copayment

When you receive services in a Wellmark Health Plan of Iowa provider's office, remember your office visit copayment listed on your ID card is due at the time of service.

See also:

• Blue Advantage Downloadable Fact Sheet (PDF)

* Available in the following Iowa counties: Benton, Black Hawk, Boone, Bremer, Buchanan, Butler, Cedar, Clarke, Clayton, Clinton, Dallas, Delaware, Dubuque, Grundy, Guthrie, Iowa, Jackson, Johnson, Jones, Keokuk, Linn, Lucus, Madison, Mahaska, Marion, Mills, Monroe, Muscatine, Polk, Pottawattamie, Scott, Shelby, Story, Tama, Warren.