HomeMy WebLinkAboutWellmark-5/4/2015 (2)OBS - OBS ID: 188067-19
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Note: This is a summary of benefits under this plan, not a statement of contract. The actual
terms and conditions of coverage will be specified in the Group Insurance Policy issued by
Wellmark or the Administrative Services Agreement between Wellmark and the entity below,
as well as the Benefits Certificate and any amendments thereto.
Benefit Summary - CITY OF WATERLOO
Group Number/BU: XA025-0001 Group Product Summary ID: 188067-19 Coverage Code:
Alpha Prefix: Benefit Dates: 7/1/2015 - 6/30/2016 Summary Status: Rating
Account Manager: Harford, DeVonne
Alt: PPO Rx $15/30/60 copay; $5600/11,200 opm
Group Information
Group Street Address 1: Mayors Office
Group Street Address 2: 715 Mulberry Street
City/State/ZIP: Waterloo , IA 50703
Product/Version: Prescription Drug Program - Custom (201112)
Account Signature
General
Wellmark Blue Cross Blue Shield of Iowa
Date 4/2 7/i
BlueRx Complete (3 -tier)
Renewal
Self-funded arrangement
Large business group (301-750)
Group is a Government Entity
Benefit period is defined as calendar year
Healthcare Reform Non -Grandfathered Plan (ACA required drugs are covered and
member cost -share is waived according to preventive care guidelines. A complete list of
recommendations and guidelines related to ACA preventive services can be found at
www.healthcare.gov)
Plan year begins on: 07/01
Eligibility
When benefits have been provided by another plan, Wellmark applies benefits the lesser of
1) the amount on the claim as the member's liability or 2) what we should have paid if the
claim was submitted to us first.
Payment
Benefit period deductibles do NOT apply
Out -of -Pocket Maximum (OPM):
Single out-of-pocket maximum is $ 5,600
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OBS - OBS ID: 188067-19 Page 2 of 2
Family out-of-pocket maximum is $ 11,200
No Wellmark to Wellmark out-of-pocket credit. Credits will not transfer from one Wellmark
employer group to another Wellmark employer group.
Days Supply (per member cost -share): 30 days
Payment Application (per member cost -share):
Tier 1 copayment is $ 15
Tier 2 copayment is $ 30
Tier 3 copayment is $ 60
Specialty Drugs Payment Application (member cost -share per 30 -day supply):
The payment application for specialty drugs is the same as listed above in the Payment
Application section. The specialty drug list can be found on www.wellmark.com under
General Pharmacy Information.
90 -Day Maintenance Supply:
At retail pharmacy: 90 -day supply of maintenance drugs available for 3 copayments OR
coinsurance per 90 -day supply.
Through mail order. 90 -day supply of maintenance drugs available for 2 copayments OR
coinsurance per 90 -day supply.
Product Selection Penalty Rule: 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 except when the provider writes
"Dispense as Written" (in this case, the member pays only the appropriate payment
application).
Utilization Management Programs apply
Benefits
Contraceptives are covered
Smoking Cessation: Prescription drugs only are covered
Coverage of specialty drugs NOT limited to Specialty Pharmacy Program
Prescription drugs covered when purchased through Participating and Non -Participating
Pharmacies. Member must submit paper claim for reimbursement when purchased through
a Non -Participating pharmacy.
Additional Information
$0 for Oral chemo medications
SPD requested.
$0 copay for smoking cessation prescription drugs.
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