WEST LIBERTY COMMUNITY SCHOOLS Educators Group Plan Options Rates Effective 7/1/2017 - 6/30/2018 Wellmark Blue Cross Blue Shield Select 250

Wellmark Blue Cross Blue Shield Select 750

Wellmark Blue Cross Blue Shield Select 1250

Provider Network

Alliance Select

Alliance Select

Alliance Select

Calendar Year Deductible

$250 Single/$500 Family Annual Deductible

$750 Single/$1,500 Family Annual Deductible

$1,250 Single/$2,500 Family Annual Deductible

Coinsurance

15% in-network; 25% out-of-network

25% in-network; 35% out-of-network

25% in-network; 35% out-of-network

Out-of-Pocket Maximum

$500 Single/$1,000 Family Annual OPM

$1,500 Single/$3,000 Family Annual OPM

$2,500 Single/$5,000 Family Annual OPM

Lifetime Maximum

Unlimited

Unlimited

Unlimited

In-Network: Deductible waived; 15% coinsurance

In-Network: Deductible waived; 25% coinsurance

In-Network: Deductible waived; 25% coinsurance

Out-of-Network: Deductible, then 25% coinsurance

Out of Network: Deductible, then 35% coinsurance

Out of Network: Deductible, then 35% coinsurance

In-Network: Deductible waived; 15% coinsurance

In-Network: Deductible waived; 25% coinsurance

In-Network: Deductible waived; 25% coinsurance

Out-of-Network: Deductible, then 25% coinsurance

Out of Network: Deductible, then 35% coinsurance

Out of Network: Deductible, then 35% coinsurance

25% coinsurance

25% coinsurance

Physician (Office) Services Physician Office Visits* Chiropractic Benefit

Doctor On Demand (Virtual Visits)15% coinsurance - Doctor and Psychologist Allergy Testing & Injections

In-Network: Deductible waived; 15% coinsurance

In-Network: Deductible waived; 25% coinsurance

In-Network: Deductible waived; 25% coinsurance

Serum subject to deductible)

Out-of-Network: Deductible, then 25% coinsurance

Out of Network: Deductible, then 35% coinsurance

Out of Network: Deductible, then 35% coinsurance

In-Network: Covered services paid at 100%

In-Network: Covered services paid at 100%

In-Network: Covered services paid at 100%

Out-of-Network: Deductible, then 25% coinsurance

Out of Network: Deductible, then 35% coinsurance

Out of Network: Deductible, then 35% coinsurance

Deductible waived for out-of-network providers

Deductible waived for out-of-network providers

Deductible waived for out-of-network providers

In-Network: Covered services paid at 100%

In-Network: Covered services paid at 100%

In-Network: Covered services paid at 100%

Out-of-Network: Ded waived, then 25% coinsurance

Out of Network: Ded waived, then 35% coinsurance

Out of Network: Ded waived, then 35% coinsurance

Included for pap smears, mammograms, and

Included for pap smears, mammograms, and

Included for pap smears, mammograms, and

Immunizations.

Immunizations.

Immunizations.

Preventive Care Routine Office Services Annual Physical** Annual Well-Woman Exam Annual Mammogram Annual Vision Exam Immunizations / flu shots Well-Baby Care (To age 7) Reminder Programs

Blue Rx Complete Prescription Drug Coverage*** Rx Benefit Period Deductible Retail Copays Rx Out of Pocket Maximum

$50 Single / $100 Family (waived for generic)

$50 Single / $100 Family (waived for generic)

$50 Single / $100 Family (waived for generic)

$10-Tier 1 / $25-Tier 2 / $40-Tier 3 / $85 Specialty

$10-Tier 1 / $25-Tier 2 / $40-Tier 3 / $85 Specialty

$10-Tier 1 / $25-Tier 2 / $40-Tier 3 / $85 Specialty

$1,500 Single / $3,000 Family Rx OPM

$1,500 Single / $3,000 Family Rx OPM

$1,500 Single / $3,000 Family Rx OPM

Facility Services Hospital Services

In-Network: Deductible, then 15% coinsurance

In-Network: Deductible, then 25% coinsurance

In-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

In-Network: Deductible, then 15% coinsurance

Deductible, then 25% coinsurance

In-Network: Deductible, then 25% coinsurance

Emergency Services Out-of-Network: Deductible, then 15% coinsurance

Out-of-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 25% coinsurance

Non-Emergency Services Out-of-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

Inpatient/Outpatient Emergency Room

Wellmark Blue Cross Blue Shield Select 250

Wellmark Blue Cross Blue Shield Select 750

Wellmark Blue Cross Blue Shield Select 1250

Facility Services Diagnostic X-ray and Lab*

In-Network: Deductible, then 15% coinsurance

In-Network: Deductible, then 25% coinsurance

In-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

Outpatient Therapy

In-Network: Deductible, then 15% coinsurance

In-Network: Deductible, then 25% coinsurance

In-Network: Deductible, then 25% coinsurance

(Speech, occupational, physical)

Out-of-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

In-Network: Deductible, then 15% coinsurance

In-Network: Deductible, then 25% coinsurance

In-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

In-Network: Deductible, then 15% coinsurance

In-Network: Deductible, then 25% coinsurance

In-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

In-Network: Deductible waived, then 15% coinsurance

In-Network: Deductible waived, then 25% coinsurance

In-Network: Deductible waived, then 25% coinsurance

Out-of-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

Infertility treatment****

$25,000 lifetime maximum for transfer procedures

$25,000 lifetime maximum for transfer procedures

$25,000 lifetime maximum for transfer procedures

Durable Medical Equipment

In-Network: Deductible, then 15% coinsurance

In-Network: Deductible, then 25% coinsurance

In-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

In-Network: Deductible, then 15% coinsurance

Deductible, then 25% coinsurance

In-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

Outpatient Surgery for impacted teeth covered.

Outpatient Surgery for impacted teeth covered.

Outpatient Surgery for impacted teeth covered.

Inpatient covered with a concurrent medical condition.

Inpatient covered with a concurrent medical condition.

Inpatient covered with a concurrent medical condition.

In-Network: Deductible, then 15% coinsurance

In-Network: Deductible, then 25% coinsurance

In-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 25% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

Out-of-Network: Deductible, then 35% coinsurance

Includes up to 10 hours of initial outpatient diabetes

Includes up to 10 hours of initial outpatient diabetes

Includes up to 10 hours of initial outpatient diabetes

self-management training within a continuous 12 month

self-management training within a continuous 12 month

self-management training within a continuous 12 month

period and up to 2 hours in each subsequent year.

period and up to 2 hours in each subsequent year.

period and up to 2 hours in each subsequent year.

Same Sex Domestic Partner

Covered as an eligible dependent (affidavit required).

Covered as an eligible dependent (affidavit required).

Covered as an eligible dependent (affidavit required).

Blue Card PPO

Provides enhanced benefits for services

Provides enhanced benefits for services

Provides enhanced benefits for services

provided by participating providers outside of Iowa.

provided by participating providers outside of Iowa.

provided by participating providers outside of Iowa.

Mental Health / Chemical Dependency Inpatient Outpatient Office

Miscellaneous Services

Ambulance Impacted Teeth Orthotic Devices Diabetic Education

Monthly Rates Single

$539.06

$496.12

$474.54

Family

$1,332.65

$1,222.25

$1,166.75

Deductible will be waived for facility and practitioner billed preventive procedures performed at an Alliance Select Facility (inpatient or outpatient). Plan allows for one routine physical examination per benefit period. A separate well-woman exam is also covered once per benefit period. Doctor on Demand: Doctor On Demand is a virtual visit platform that immediately connects you to a board-certified physician by live video on your smartphone, tablet or computer. - Member cost to use Doctor on Demand is the same as that for an Office Visit. Select RX: When a brand drug is obtained and there is an equivalent generic drug available, the member is responsible for paying their payment obligation for the equivalent generic (i.e. lowest payment application) and any remaining cost difference up to the maximum allowed fee for the brand name drug. *Lab or x-ray charges billed by an Alliance Select hospital in conjunction with office visits are NOT subject to deductible. However, the following are subject to deductible: EKG, EEG, ECG, MRI, MRA, CT, radiation therapy, and Ultrasounds (only with a medical diagnosis). **Health maintenance exams (physicals) for school, sports, insurance, employment, and travel will not be covered. Physicals for routine preventive care continue to be covered. ***Mandated Contraceptives include oral, injected and implanted contraceptives, and contraceptive devices. ****Eligible infertility charges are covered as any other service and coinsurance will apply to annual out-of-pocket maximum. This is a brief description only and does not replace the contract.

Benefits Summar All Plan 7-1-17 to 6-30-18.pdf

Annual Mammogram Deductible waived for out-of-network providers Deductible waived for out-of-network providers Deductible waived for out-of-network ...
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