Primary Care Provider (PCP) designations

A long-term relationship between a patient and their PCP can be associated with better overall health and lower hospital and emergency room use. That's why the Wellmark Blue Cross and Blue Shield health plan may feature benefit differentials when patients establish and visit their designated PCP.

Members can designate:

• MD/DO, ARNP or PA who provides services in family practice, general practice, internal medicine, geriatrics or pediatrics
• These providers must meet overall credentialing and provide documentation to be considered a PCP with Wellmark.
• Log in to submit a medical authorization. Please refer to the Jiva user guide.

Preventive care

Preventive services are covered at $0 member out-of-pocket cost when performed by an in-network provider.

Wellmark Blue HMO

Preventive services received by an out-of-network provider will not be covered.

Wellmark Blue POS

Preventive services received by an out-of-network provider will be subject to the same cost-share as Wellmark Blue POS non-PCP/specialists.

Primary care

Primary care services performed by the member's designated PCP deliver the lowest member out-of-pocket costs.

Primary care services from another in-network PCP or specialist are covered at a slightly higher cost-share, such as:

• Maternity care from an in-network OB/GYN or Certified Nurse Midwife
• Routine vision examinations from an in-network optometrist or ophthalmologist
• Chiropractic services from an in-network chiropractor
• Occupational therapy services from an in-network occupational therapist
• Physical therapy services from an in-network physical therapist
• Speech therapy from an in-network speech therapist
• In-network mental health and chemical dependency services

Log in to the Provider Portal to determine if a member's contract includes coverage for preventive care.

Out-of-Network Care

Wellmark Blue HMO out-of-network services are not covered, with the exception of emergency care. Referral to an out-of-network provider will follow Wellmark's standard approval process.

Wellmark Blue POS out-of-network services are the highest member out-of-pocket cost. Referral to an out-of-network provider will follow Wellmark's standard approval process.

Additional Information

The Health Management section of the Wellmark Provider Guide includes:

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

Quality tip sheets to support HEDIS and NCQA accreditation.

Wellmark Health Plan of Iowa, Inc.

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

• Wellmark Blue HMO
• Wellmark Blue POS