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HomeMy WebLinkAboutWellmark Signed Renewal 2023-2024 - 5.15.2023Wellmark0 © 2019 Wellmark Inc. All rights reserved. Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Health Plan of Iowa, Inc., Wellmark Blue Cross and Blue Shield of South Dakota, Wellmark Value Health Plan, Inc., and Wellmark Administrators, Inc. are independent licensees of the Blue Cross and Blue Shield Association. ACCOUNT INFORMATION AND BINDER AGREEMENT CITY OF WATERLOO 7/1/2023 00014392 0000XA025 Account Legal Name Effective Date Physical Address Account Key Group Number 715 MULBERRY ST Address Line 1 WATERLOO City Address Line 2 IA 50703-5714 State Zip Billing Address (if different than physical address) ❑ Alternate Location 715 MULBERRY ST ❑ 3rd Party Billing Service (If checked, account acknowledges the Wellmark Group Statement or premium invoice, delivered periodically to any third party service provider, can be viewed by account, by registering for electronic billing at Wellmark. com.) Address Line 1 WATERLOO City Authorized Health Plan Representatives Address Line 2 IA 50703-5714 State Zip An authorized health plan representative is an employee of the Account (not the Producer) who is authorized to request and receive the minimum necessary protected health plan information about the group health plan's members in order to perform their day-to-day job functions of administering benefits for participants of the plan. The following individual employees are authorized health plan representatives. 7/1/2023 Effective Date Name Title Email Phone Lance Dunn HR Director 319-291-4522 x 30Qi Lance.dunn@waterloo-ia.org 1 Authorized Health Plan Representatives (continued) Name Title Email Phone Nikki Fischels 319-291-4522 EXT 33j HR Specialist, Payroll & BE NICOLE FISCHELS@WATERLE Producer Designation No Producer Designated Account requests that Wellmark recognize the following individual and firm as the designated employee benefits and insurance producer. Designation of Producer Effective Date Primary Producer Name Producer Firm Name Producer Number Producer Firm Address 1 City State Zip Primary Contact Name Email Phone Authorization to Release Group Health Plan Information and Protected Health Information to Consultant By signing below, the Employer hereby authorizes and directs Wellmark, Inc. to disclose to the above, designated Consultant certain group health plan information and Protected Health Information regarding participants in the employer -sponsored group health plan for the purpose of the Consultant's administration of the Employer's group health plan. The Employer authorizes Wellmark to disclose such information via secure online access through Wellmark's website, including the following website applications which contain information the Employer considers necessary to provide to the Consultant in order to conduct operations of the Employer's group health plan: • Member Maintenance/Update Member Information • Employer Reports • Update Other Insurance Information/Coordination of Benefits • Check Claims Status • eBilling Services • Eligibility Verification Benefits Information (EVBI) ❑ Yes, I authorize my Consultant to access this information. By signing below, the Employer authorizes Wellmark to provide the Consultant access to this information on an ongoing basis without further authorization. The Employer represents and agrees that 1) The Consultant is considered a Business Associate of the Employer, not Wellmark, Inc., 2) The information to be disclosed is considered confidential, 3) The Consultant has provided satisfactory assurance to the Employer that the Consultant will properly safeguard and not further disclose the information, 4) Wellmark shall not be liable or responsible for any misuse or wrongful disclosure of such information by the Employer or its Consultant, 5) The Employer agrees to indemnify and hold Wellmark harmless from and against any claim, cause of action, liability, damage, cost or expense, including attorney's fees and court or proceeding costs, arising out of, or in connection with, any misuse or wrongful disclosure of the information by the Employer, or its Consultant. The Employer acknowledges that the Consultant will be required to agree to Wellmark's website terms and conditions upon registering for access to such information. 2 Producer Designation (continued) ® No, I do not authorize my Consultant to access this information. Secondary Consultant There is no secondary consultant on file. You may add one below. Secondary Consultant Name Email Address Phone Authorization to Release Protected Health Information for Third -Party Explanation of Benefits Not Applicable General Account Information Devonne Harford 00000044 Wellmark Account Manager Rep ID# February Contact Month July CWW Plan Year Month Unique Alpha Prefix Wellmark IS the Exclusive Carrier Blues Enroll Enrollment Method Open Enrollment Period* `Enrollment Period is the period in which employees can enroll within a plan or plans, and/or when written application materials are provided to employees, if sooner. The account will hold an open enrollment: I❑i'YES ❑ NO If YES, fill in open enrollment period dates: l /, Starting date Ending date Funding Arrangement ❑ This self -funded account will be developing our own SBCs to distribute.(lfyou modifyoroptout of using the standard, Wellmark-provided SBCs, please be aware that Wellmark will not be able to retain or distribute your customized SBCs to your employees.) Self Funded Funding Arrangement Wellmark 60/12 Ind. SL $100K Aqq SL 120% Stop Loss Carrier Stop Loss Terms/Lines of Business Terminal Rider applies: ❑ YES ® NO (If yes, Signed exhibit page attached.) 3 General Account Information (continued) Value Based Program elected : ❑ YES ® NO Product ® Health ® Pharmacy ❑ Dental A group health plan may designate a state benchmark plan other than Iowa or South Dakota for purpose of determining compliance with essential health benefit (EHB) requirements. Benchmark Exception for EHB? ❑ YES ® NO If yes, list State Guarantees Not Applicable Health Care Management Services Self Funded - LIVONGO See Attached Rate Exhibit Representation of Grandfathered Status under the Affordable Care Act Not Applicable COBRA Not Applicable 4 This Large Group Account Information and Binder Agreement ("Binder Agreement) serves solely as evidence of Wellmark's agreement to provide the health insurance coverage or administrative services and to provide services for any applicable stop loss insurance coverage indicated above. The Account agrees to the terms and payment obligations stated herein and agrees to pay Wellmark the applicable rates, administrative fees, and/or stop loss premium stated in the attached documentation. Execution of the Binder Agreement by the Account authorizes Wellmark to implement the administration of this coverage including the processing and settlement of claims for members of the Account's group health plan incurred within the Rating Period stated in the attached Rating Exhibit. On or about the effective date of coverage, Wellmark shall issue and execute a definitive agreement which may be a Group Insurance Policy, Administrative Services Agreement and or Stop Loss Policy, depending on the nature of the group health plan. The definitive Agreement will set forth the rights and responsibilities of Wellmark and the Account. Account's payment to Wellmark of the applicable fees as of the effective date is evidence of Account's agreement to the terms specified in the definitive agreement. Signatures on this Binder Agreement confirm that the Binder Agreement and the subsequent definitive agreement are issued for delivery in either Iowa or South Dakota, as applicable. Account understands and agrees that Wellmark defines a National Account as any company headquartered in Wellmark's service area of Iowa or South Dakota but which also has employees working at locations in other states whose claims are processed through the Blue Cross and Blue Shield Association's Blue Card program. If the Account is not headquartered in Wellmark's service area, coverage may be limited to employees associated with Account locations in Wellmark's service, and coverage will be void for any persons associated with Account locations outside Wellmark's Service Area unless express consent is obtained from the local Blue Cross or Blue Shield licensee. Account acknowledges and agrees that it has reviewed and approved this Binder Agreement and all attachments. Account acknowledges Wellmark will rely on the information contained in this Binder Agreement, and all of the attachments hereto, including but not limited to the SBC Employer Data Form, Medicare Secondary Payer Addendum, Rate Exhibits, Health and Care Management rates, Online Benefit Summary (OBS), COBRA Agreements, representations of grandfathered status and any performance guarantee information. Account represents to Wellmark that the information contained herein is correct. This Binder Agreement shall expire upon Wellmark's issuance and execution of the definitive agreement (either the Group Insurance Policy, or Administrative Services Agreement and Stop Loss Policy, if applicable), EXCEPT that any COBRA Agreements, Health and Care Management Programs/Services Rating Exhibit, will remain in effect and become a part of the definitive agreement. It is understood that the Wellmark may continue to rely on the designations of individuals and authorizations made herein until the Account withdraws such designations or authorizations or provides updated designations and authorizations. It is understood and agreed that the terms and conditions of the definitive agreement and benefits document(s) issued by Wellmark to the Account, and the terms and conditions of the definitive stop loss policy issued by stop loss carrier, if any, shall govern and control the terms stated in this Binder. Any inconsistency between this Binder Agreement, including attachments, and any subsequently issued definitive agreement(s) shall be construed in favor of the subsequently issued definitive agreement. This Binder Agreement shall be governed in accordance with Iowa Law. ACCOU By (sign here) piked Title For Internal Use Only IA Group is renewing as is. Ines. DLAh �l Printed Name 6//G /01-3 Date Renewal -No Benefit Change Notes i4'rllmnCS Et4 lh ei ee an Irgereq*--At Ai Self Funded FINAL Renewal Rates Group Name: City of Waterloo Account Key: 00014392 Renewal Period: 07/01/2023 to 06/30/2024 Current Benefit Offerings Current Enrollment OBS #188067-68 / 188067-69 Alliance Select Deductible: $500/$1,000;$1,000/$2,000 Coinsurance: 20% / 40% OPM: $1,000/$2,000;$2,000/$4,000 Office Visit Copay: See OBS BlueRx Complete Deductible: $0 / $0 Copay: $15/$30/$50 Individual Stop Loss Aggregate Stop Loss Administrative Fees - Health Administrative Fees - PBM Consultant Fee Total Administrative Fees Network Access Fee Expected Claims Admin, NAF & Stop Loss Fees Estimated Suggested Rates* Attachment Points Admin, NAF & Stop Loss Fees Estimated Max Liability to Fund* 125 Single 443 Family 568 Total Level Fee/Contract $100, 000 120% w/weekly settlement Single Family $769.04 $1,922.60 $151.10 $377.75 $920.14 $2,300.35 $922.85 $151.10 $1, 073.95 $2,307.13 $377.75 $2,684.88 $270.76 $2.49 $43.85 $1.10 $0.00 $318.20 $9.67 Stop Loss Terms Contract: 60/12 Monthly Aggregate Option: No Payment Terms: Actual Weekly `Actual results may vary. Also, rates provided include administrative costs based on the entire group population. Individual Stop Loss includes coverage for Health and Drug and is based on a lifetime maximum of unlimited. Aggregate Stop Loss includes coverage for Health and Drug. The maximum Aggregate reimbursement is unlimited. Employer Signature: Date: (i'. /t �l�J Estimated Annual Premium Based on Current Enrollment $1,845,500 $16, 972 $298,882 $7,498 $0 $2,168,851 $65,911 Annual Projection $11,374,102 $2,234,769 $13,608,871 $13,648,978 $2,234,769 $15,883,747 Comments: v50891 Independent Licensee of the Blue Cross and Blue Shield Association Proposal Date: 4/5/2023 Wellmark Y.kllrna+k Bkt. Crr.: and Aw Shed n an Irdeper}Cif I:censee 9f Ire Blue GCsSanc BIL,t 511.ek: Acsrrvdfip, Self Funded FINAL Renewal Rates Group Name: City of Waterloo Account Key: 00014392 Renewal Period: 07/01/2023 to 06/30/2024 Consultant fee, if applicable, is an amount determined by the consultant and employer, and included here for the convenience of the employer to understand the total cost of services from Wellmark and the consultant. The consultant fee will be invoiced by Wellmark pursuant to agreement between Wellmark, Employer and Consultant. Wellmark is not providing any legal or professional advice with regard to compliance of any federal or state law, regulations, or guidance. Law, regulations and guidance on specific provisions has been and will continue to be provided by the appropriate federal and state agencies and regulators. The information provided reflects Wellmark's understanding of the most current information and is subject to change without further notice. Please note that plan benefits, rates, renewal rate adjustments, and rating impact calculations are subject to change and may be revised during a plan's rating period based on guidance and regulations issued by the appropriate federal and state agencies and regulators. Wellmark makes no representation as to the impact of plan changes on a plan's grandfathered status or interpretation or implementation of any other provisions of law or regulation. Wellmark will not determine whether coverage is discriminatory or otherwise in violation of Internal Revenue Code Section 105(h). Wellmark also will not provide any testing for compliance with Internal Revenue Code Section 105(h). Wellmark will not be held liable for any penalties or other losses resulting from any employer offering coverage in violation of section 105(h). Wellmark will not determine whether any change in an Employer Administered Funding Arrangement affects a health plan's grandfathered health plan status under ACA or otherwise complies with ACA. Wellmark will not be held liable for any penalties or other losses resulting from any Employer Administered Funding Arrangement. For purposes of this paragraph, an "Employer Administered Funding Arrangement" is an arrangement administered by an employer in which the employer contributes toward the member's share of benefit costs (such as the member's deductible, coinsurance, or copayments) in the absence of which the member would be financially responsible. An Employer Administrative Funding Arrangement does not include the employer's contribution to health insurance premiums or rates. The subrogation and third -party liability recovery vendor(s) retain a service fee calculated as a percentage of the recovered amount after deductions for attorneys' fees and costs. For subrogation or third -party liability cases initiated during the Rating Period, the subrogation/third- party liability recovery vendor's service fee is 19.5% of the recovered amount. This fee is subject to change. The final recovered amount received from the vendor is credited to Account. Wellmark's agreement with the subrogation and third -party liability recovery vendor may from time to time allow for the application of no vendor service fees to amounts recovered during that period of time. Any subrogation or third -party liability recovery amount obtained by the vendor on behalf of the Account during that time period will be provided to Account without application of the vendor service fee. v50891 Independent Licensee of the Blue Cross and Blue Shield Association Proposal Date: 4/5/2023 Wellmark® Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association. MEDICARE COMPLIANCE The purpose of this communication is to notify employers of the mandatory reporting requirements of the Medicare, Medicaid, and SCHIP Extension Act of 2007 which were passed into law in July 2008. Your cooperation in providing the necessary employer data and data for each employee and dependent is needed in order to comply with the requirements. The Section 111 mandates of the law help payers identify when the Centers for Medicare and Medicaid Services (CMS) should pay secondary to employer group health coverage. The goal includes reducing the amount CMS may pay as primary when they should have paid as secondary. Under the requirements, all health plan, liability, no fault and workers compensation coverages must register with CMS as a Responsible Reporting Entity (RRE) and must report to CMS employer and member information. In order to fulfill the mandated requirements and report accurately to CMS, Wellmark, as a RRE, must gather and groups must provide the following information: • Employer Tax Identification Number (ETIN) • Evidence of status as a Commonly Owned/Controlled Group of Organizations, Multi/Multiple Employer Group health plan (such as an Association or Trust), Hour Bank or Union health plan • Total number of group employees/group size • Social Security Numbers (SSNs) or Health Insurance Claim Numbers (HICNs) of active employees, spouses, domestic partners • SSNs or HICNs for those dependents with end stage renal disease (ESRD) or disabled • Status of all employees and effective date of that status (i.e. active, COBRA, retired) • Disability information begin or end dates, if known Please take a moment to complete the Confirmation of Medicare Secondary Payer (MSP) Addendum form. This will allow us to capture your employer data for reporting to CMS. Member data is gathered through the use of the group's existing enrollment and eligibility data collection channels, which may include paper applications or electronic data exchanges and should be provided through those processes. Failure to provide the group information requested on the attached Confirmation of MSP Addendum can result in penalties being assessed to the group including, but not limited to, $1,000 per day per member f,or not accurately reporting to CMS and/or an excise tax equivalent to 25 percent of the employer's group health pan expenses for the relevant year. Wellmark Blue Cross and Blue Shield of Iowa I 1331 Grand Avenue I PO Box 9232 I Des Moines, Iowa 50306-923 I wellmark.com N-2305 5/14 AN-T Page 1 of 2 Clear Form Wellmark® Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association. FOR ADMINISTRATIVE USE ONLY New Group: Group # i Coverage Effective Date: / / CONFIRMATION OF MSP ADDENDUM ALL NEW AND RENEWAL GROUPS ARE REQUIRED TO SUBMIT A COMPLETED FORM. FAILURE TO SUBMIT A COMPLETED FORM WILL DELAY THE INITIAL ENROLLMENT OR RENEWAL PROCESS UNTIL THIS FORM IS SUBMITTED. Part A - Employer Information Please complete a separate confirmation form for each Employer Tax Identification Number you use to report employee earnings to the Internal Revenue Service (IRS). See the Medicare Secondary Payer Definitions page (M-1756) for more information on terms shown in italics. Employer Tax Identification Number: WTI I n IU I S❑ [ C Group Number (Renewing Groups Only): /XA 0D 5 Employer Name: 0/ OP141 a,T,e r/Oc Employer Address: ! 5 r / [ Ltl r�c,Yl't St. City: L,tiOL-�,�106 State: Zip: So 71? Contact Person: LaiiC,P ,Dunn Telephone Number: 3)q -aq/- 14303 E-mail Address (optional): ((mee.clunflc) L11erlao-la. 05 1. Did your organization make contributions on behalf of any employee who was covered under a collectively bargained Health and Welfare Fund (i.e., union plan) during the previous calendar year? 2. Did you have 20 or more employees for 20 or more calendar weeks (this includes all full-time, part time, intermittent, leased and/or seasonal employees, not just those eligible or enrolled employees) during the previous or current calendar year? If no, in the event you experience a change, you must notify Wellmark when this change occurs. 3. Did you have 100 or more employees during 50 percent of your business days (this includes all fulli-time, part-time, intermittent, leased and/or seasonal employees, not just those eligible or enrolled employees) during the previous calendar year? 4. Did your organization participate in a multi or multiple employer group health plan (more than one employer in group, i.e., Multiple Employer Welfare Association) during the previous calendar year? If yes, what is the name and address of the multi or multiple employer plan? Name: Address: City: State: Zip: 5. Was your organization part of a commonly owned or commonly controlled group of organizations d.iring the previous calendar year? If yes, what is the name and address of the commonly owned/controlled entity? Name: Name: Address: Address: City: State: Zip: City: Part B - Employer Certification I certify that the information provided is accurate and truthful. All information will be used to identify he Medicare Secondary Payer status of Medicare -enrolled employees. \Tes 0 No ides D No D No El Yes ifrrio Yes b1lo Signature State: Date Zip: Send cdrf pleted MSP form bused on following: IA & SD Large Groups (new or renewal) IA & SD Small Groups (new or renewing with benefit changes) IA Small Groups renewing with no benefit change - send this form to: SD Small Groups renewing with no benefit change Submit this completed MSP form with group's health plan new or renewal paperwork Submit this completed MSP form with group's health plan new or renewal paperwork Fax: (515) 376-9044 or Wellmark, Inc. PO Box 9232 — Mail Station 3W396 Des Moines, IA 50306-9232 Send this completed MSP form to: Wellmark, Inc. PO Box 5023 — Station 338 Sioux Falls, SD 57117-5023 N-2305 5/14 AN-T Page 2 of 2 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- Group Product Summary ID: 188067-68 Coverage Code: ProductlD: Prefix: CWW Benefit Dates: 07/01/2023 - 06/30/2024 Summary Status: Rating Completed Account Manager: Harford, DeVonne CITY OF WATERLOO PPO Group Information Group Street Address 1: 715 Mulberry Street Group Street Address 2: City/State/ZIP: Waterloo , IA 50703-5714 Product/Version: Alliance Select (201009) General Renewing group Self -funded arrangement Non-ERISA group plan This plan or policy does meet minimum value Group is a government entity Union group Plan year begins on: 07/01 Healthcare Reform Non-Grandfathered Plan Benefit period is calendar year BlueCard PPO - In states with no PPO or PPO specialty, providers are treated as PPO as determined by Wellmark and the local Blue plan Additional general information: Summary Plan Description (SPD) produced by Wellmark Eligibility An eligible child is married or unmarried and is under 26 years of age. An eligible child is an unmarried dependent full-time student regardless of age. An eligible child is disabled before age 26 and remains unmarried after age 26. An eligible child is unmarried and disabled while a full-time student after age 26. Dependent coverage terminates at the end of the month Two-way rate (single/family) Unmarried domestic partners are NOT covered Certificate coverage ends at the end of the month Subrogation applies Standard administration of coordination of benefits (COB) Routine maternity benefits apply to employee/spouse/dependent Do not include ERISA Information Requirements language Coordination of benefits rules apply to members when Medicare is the primary payer Preexisting Condition Exclusion Periods New hires and special enrollees are covered when first eligible or at each group renewal. New hires and special enrollees are NOT subject to preexisting condition exclusion periods Late enrollees (a member who is not a new hire or special enrollee) may enroll at group's enrollment period in January Late enrollees are NOT subject to preexisting condition exclusion periods Deductibles Coverage has benefit period deductibles Single deductible for PPO providers is: $ 500 Single deductible for non-PPO providers is: $ 1,000 Family deductible for PPO providers is: $ 1,000 Family deductible for non-PPO providers is: $ 2,000 Tiered deductible amounts are aggregate (both ways) - PPO and non-PPO deductibles apply to each other Member has benefits after single deductible met. Entire family has benefits after family deductible has been met (or if a two -person amount is listed, then for two -person contracts, entire family has benefits after the two -person deductible has been met) Deductible from the previous 4th quarter will NOT carry over to this year's benefit period deductible Common accident deductible does NOT apply No Wellmark-to-Wellmark deductible credit. Credits will not transfer from one Wellmark employer group to another Wellmark employer group. Telehealth services provided by a physician's office follow office visit deductible administration Physician services for well -child care are NOT subject to the deductible Physician services for newborn care are NOT subject to the deductible Facility services for well -child care are NOT subject to the deductible Facility services for newborn's initial hospitalization are NOT subject to the deductible PPO outpatient preventive care is NOT subject to the deductible PPO office services and PPO independent lab fees are NOT subject to the deductible PPO urgent care services are NOT subject to the deductible Most outpatient x-ray/lab services from PPO facilities are subject to the deductible One postpartum home visit is NOT subject to the deductible All services with copays are NOT subject to the deductible Preventive care (other than routine vision exams) from PPO providers is NOT subject to the deductible Preventive care from participating providers is NOT subject to the deductible Preventive 3D mammography (digital breast tomosynthesis) from PPO or participating providers is NOT subject to the deductible Routine vision exams from PPO providers are NOT subject to the deductible Prosthetic limbs from PPO providers are NOT subject to the deductible Other services NOT subject to the deductible are: PPO independent lab for MHCD services Copay Primary Care Practitioner (PCP) is defined as General Practice, Family Practice, Internal Medicine, Obstetrics/gynecology, Pediatricians, Nurse Practitioners, Certified Nurse Midwives, and Physician Assistants. Office PCP copay - includes MHCD unless stated otherwise is: $ 20 Chiropractors, Speech Pathologists, Physical Therapists, and Occupational Therapists office copay amount is the same as the office PCP amount listed above All other providers are Non -Primary Care Practitioners (Non -PCP). Office non -PCP copay - includes MHCD unless stated otherwise is: $ 40 Office visit copay includes telehealth services provided by a physician's office Office visit copay applies to services received from PPO practitioners Office visit copay is taken once per practitioner per date of service Office visit copay applies to any office services Preventive care (other than routine vision exams) is NOT subject to the office visit copay (copay is waived for preventive care) Preventive 3D mammography (digital breast tomosynthesis) is NOT subject to the office visit copay (copay is waived for preventive 3D mammography) Routine vision exams are NOT subject to the office visit copay (copay is waived for routine vision exams) Services NOT subject to office visit copay are: MHCD services Office visit copay applies to the out-of-pocket maximum. Copay does NOT continue after the out-of-pocket maximum is met Deductible does NOT follow office visit copay Coinsurance does NOT follow office visit copay The following services have a different office visit copay: Acupuncture: $20 copay Urgent care copay is: $ 20 Urgent care copay applies to services received from both facility and practitioner combined Urgent care copay applies to services received from PPO providers Urgent care copay is taken once per provider, per date of service Urgent care copay applies to all urgent care services Urgent care copay applies to the out-of-pocket maximum. Copay does NOT continue after the out-of-pocket maximum is met Deductible does NOT follow urgent care copay Coinsurance does NOT follow urgent care copay Telehealth vendor copay is: $ 20 Telehealth vendor mental health/chemical dependency copay is: $ 0 Telehealth vendor copay is taken once per provider per date of service Telehealth vendor copay applies to the out-of-pocket maximum. Copay does NOT continue after the out-of-pocket maximum is met Deductible does NOT follow telehealth vendor copay Coinsurance does NOT follow telehealth vendor copay Coinsurance Coinsurance for PPO providers is the following percentage: 20 Coinsurance for non-PPO providers is the following percentage: 40 Telehealth services provided by a physician's office follow office visit coinsurance administration One postpartum home visit is NOT subject to coinsurance Services subject to copay are NOT subject to coinsurance Preventive care (other than routine vision exams) from PPO providers is NOT subject to coinsurance Preventive care from participating providers is NOT subject to the coinsurance Preventive 3D mammography (digital breast tomosynthesis) from PPO or participating providers is NOT subject to coinsurance Routine vision exams from PPO providers are NOT subject to coinsurance Other services NOT subject to coinsurance are: PPO independent lab for MHCD services Out of Pocket Maximum Out-of-pocket maximums apply Single out-of-pocket maximum for PPO providers is: $ 1,000 Single out-of-pocket maximum for non-PPO providers is: $ 2,000 Family out-of-pocket maximum for PPO providers is: $ 2,000 Family out-of-pocket maximum for non-PPO providers is: $ 4,000 Participating providers are subject to the PPO OPM Tiered out-of-pocket maximum amounts are aggregate (both ways) - PPO and non-PPO out-of-pocket maximum amounts apply to each other Member has benefits after single OPM met. Entire family has benefits after family OPM has been met (or if a two -person amount is listed, then for two -person contracts, entire family has benefits after the two -person OPM has been met) Deductible amounts apply to the out-of-pocket maximum Coinsurance for all services apply to the out-of-pocket maximum Deductible from the previous 4th quarter will NOT carry over to the out-of-pocket maximum for this year Coinsurance from the previous 4th quarter will NOT carry over to the out-of-pocket maximum for this year No Wellmark-to-Wellmark out-of-pocket credit. Credits will not transfer from one Wellmark employer group to another Wellmark employer group Lifetime Maximum Lifetime maximum is unlimited Lifetime maximum for hospice respite is limited to 15 days inpatient/15 days outpatient Facility Services Iowa Psychiatric Medical Institutions for Children are covered according to state mandate The cost of blood and administration is covered Nonparticipating facility claims are based on maximum allowable fee Facility based skilled nursing services are covered. Services must be ordered and certified by your attending physician. Practitioner Services Advanced nurse practitioners are covered Physician assistants are covered Licensed marriage family therapists are covered. Licensed mental health counselors are covered. Dental treatment for accidental injury (excluding acts of chewing) is covered if initiated within 12 months of accident and completed within 24 months Surgical removal of impacted teeth is covered as an inpatient with a concurrent medical condition. Outpatient services are covered without a concurrent medical condition Treatment of temporomandibular joint disorder is covered, except for routine dental services, dental restorations/extractions, and orthodontic treatment Chiropractor services are covered as medically necessary ABA Therapy is covered Preventive Care/Immunizations/Mammography Preventive physical exams are covered. A separate gynecological exam is also covered One preventive physical exam per member per benefit period is covered Women's preventive care services are covered according to the ACA mandate Immunizations are covered (Travel Immunization excluded) Mammography benefits are covered one per benefit period Preventive Pap smears are unlimited One routine vision exam (including refraction) per benefit period is covered Well -child and newborn care is covered according to mandate Hearing aids are covered (and are subject to applicable cost share unless otherwise indicated) as follows: limited to $1,000 every 36 months Routine hearing exams are covered one per benefit period Prescription Drugs/Contraceptives Retail drugs are covered under a Prescription Drug Program Prescription drugs/items for smoking cessation are covered under a Rx Program; related exams are covered under health Smoking cessation consultations are included as part of preventive care Contraceptives are covered. Oral and drug delivery devices, such as insertable rings and patches, are covered under a Rx Program; injected, implanted, and medical devices, such as intrauterine devices and diaphragms, are covered under health Contraceptives covered under health are included as part of preventive care Most specialty drugs are covered under the Prescription Drug Program, NOT under Health. Additional information for specialty drugs can be found at Wellmark.com Other Services Supplemental accidental injury benefits are NOT covered Reminder Programs are NOT available Diabetic education programs are covered from state certified programs for members diagnosed with diabetes Hospice services are covered Infertility benefits are NOT covered Coverage for Home Medical Equipment is unlimited. Bariatric surgery is covered Major organ transplants are covered. Prior approval required. Transplants are NOT limited to Blue Distinction Centers for Transplant Telehealth services provided by Doctor on Demand are covered for the following services: Medical/Pediatric Mental health/chemical dependency services Telehealth practitioner services are covered Wigs are covered as follows: Wigs are covered with a diagnosis of cancer or alopecia without cost share and limited to $1000 per benefit period. Allowed amount is based on billed charge Massage therapy is NOT covered Acupuncture is covered Elective abortions are NOT covered Bereavement counseling is covered Family counseling is covered Diabetes Prevention services billed by Livongo are covered Diabetes Management services billed by Livongo are covered MHCD Mental health/chemical dependency treatment is covered Additional Information Cost share waived for PPO and Par routine services including glucose screening without Al C, general health panel, basic or comprehensive metabolic panels and lipids panel. These services are covered when submitted with a routine physical dx Cost share is waived for PPO and Par routine services including PSA testing, thyroid testing and venipuncture associated with labs. These services are covered when submitted with a routine physical diagnosis 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- Group Product Summary ID: 188067-69 Coverage Code: ProductlD: Prefix: Benefit Dates: 07/01/2023 - 06/30/2024 Summary Status: Rating Completed Account Manager: Harford, DeVonne CITY OF WATERLOO PPO RX Group Information Group Street Address 1: 715 Mulberry Street Group Street Address 2: City/State/ZIP: Waterloo , IA 50703-5714 Product/Version: Prescription Drug Program - Custom (201112) SIGN HERE General Wellmark Blue Cross Blue Shield of Iowa BlueRx Complete (3-tier) Renewal Self -funded arrangement Non-ERISA group plan 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 Additional information for General section: Summary Plan Description (SPD) produced by Wellmark 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 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. Member has benefits after single OPM met. Entire family has benefits after family OPM has been met (or if a two -person amount is listed, then for two -person contracts, entire family has benefits after the two -person OPM has been met) 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 $ 50 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. Additional information for specialty drugs can be found at Wellmark.com Pharmacy Durable Medical Equipment (DME): Pharmacy durable medical equipment in -network coinsurance is % 20 Pharmacy durable medical equipment out -of -network coinsurance is % 40 90-Day Supply: At retail pharmacy: 90-day supply of drugs available for 3 copayments OR coinsurance per 90-day supply Through mail order: 90-day supply of 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). Benefits Contraceptives are covered Weight reduction drugs are NOT covered Erectile Dysfunction drugs are covered Prenatal Vitamins drugs are covered Smoking Cessation: Prescription drugs only are covered Specialty Drugs must be obtained through CVS Specialty Pharmacy only CVS Specialty Copay Card Program applies Prescription drugs and pharmacy durable medical equipment (if covered) covered when purchased through Participating and Non -Participating Pharmacies. Member must submit paper claim for reimbursement when purchased through a Non -Participating pharmacy. Utilization Management Programs apply Opioid Medication Management Program applies Additional information for Benefits section: Smoking cessation prescription drugs: copay is waived Additional Information Oral chemo medications: cost share is waived