Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Coverage Period:

07

/01/2019 –

06/30/2020

Coverage for:

Single & Family |

Plan

 Type:

PPO

Centerville Comm School District PPO

	The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.wellmark.com or call 1-800-524-9242. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary or call 1-800-524-9242 to request a copy.	
Important Questions	Answers	Why this Matters:	
What is the overall deductible?	$3,000 person/$6,000 family per calendar year.	Generally, you must pay all the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.	
Are there services covered before you meet your deductible?	Yes. Well-child care, ambulance services, in-network preventive care, innetwork independent labs, in-network prosthetic limbs and services subject to health and drug card copayments are covered before you meet your deductible.	This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventivecare-benefits/.	
Are there other deductibles for specific services?	No. There are no other deductibles.	You don’t have to meet deductibles for specific services.	
What is the out-of-pocket limit for this plan?	Health: $6,000 person/$12,000 family per calendar year.  Drug Card: $6,000 person/$12,000 family per calendar year. The In-Network health and drug card out-of-pocket maximum amounts accumulate together.	The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.	
What is not included in the out-of-pocket limit?	Premiums, balance-billed charges, and health care this plan doesn’t cover.	Even though you pay these expenses, they don’t count toward the out-of-pocket limit.	
Will you pay less if you use a network provider?	Yes. See www.wellmark.com or call 1800-524-9242 for a list of network providers.	This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-ofnetwork provider for some services (such as lab work). Check with your provider before you get services.	
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Important Questions	Answers	Why this Matters:	
Do you need a referral to see a specialist?	No.	You can see the specialist you choose without a referral.	
		
 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.	
Common
Medical Event	Services You May Need	What You Will Pay
In-Network (IN)
Provider
(You will pay the least)	What You Will Pay
Out-of-Network
(OON) Provider
(You will pay the most)	Limitations, Exceptions, & Other Important
Information	
If you visit a health care provider’s office or clinic	Primary care visit to treat an injury or illness	$15 copay per date of service	20% coinsurance	------None------	
	Specialist visit	$15 copay per date of service	20% coinsurance	------None------	
	Preventive care/screening/ immunization	No charge	20% coinsurance	One preventive exam and one gynecological exam per calendar year. Mammograms covered according to the IA Mandate schedule. Well-child care is covered to age 7.
You may have to pay for services that aren't preventive.
Ask your provider if the services you need are preventive.
Then check what your plan will pay for.	
If you have a test	Diagnostic test (x-ray, blood work)	10% coinsurance	20% coinsurance	For a test in a provider's office or clinic, your cost is included in the cost-share listed above. Waive cost-share on in-network independent lab services for mental health/ substance abuse.	
	Imaging (CT/PET scans, MRIs)	10% coinsurance	20% coinsurance	For a test in a provider's office or clinic, your cost is included in the cost-share listed above.	

Common
Medical Event	Services You May Need	What You Will Pay
In-Network (IN)
Provider
(You will pay the least)	What You Will Pay
Out-of-Network
(OON) Provider
(You will pay the most)	Limitations, Exceptions, & Other Important
Information	
If you need drugs to treat your illness or condition
More information about prescription drug coverage is at www.wellmark.com/ prescriptions.	Tier 1	$5 copay per prescription	Not covered	Drugs listed on Wellmark's Blue Rx Value Plus Drug List are covered. Drugs not on this Drug List are not covered.
1	copay for 30-day supply.
2	copays for 90-day supply (Retail and mail order maintenance).
30-day supply for prescription drugs (Specialty drugs). Specialty drugs are covered only when obtained through the CVS Specialty Pharmacy Program.
See wellmark.com/prescriptions for information about drugs and drug quantities that require prior authorization by Wellmark to be covered by your plan.	
	Tier 2	$12 copay per prescription	Not covered		
	Tier 3	$25 copay per prescription	Not covered		
	Specialty drugs	Preferred: $100 copay per prescription
Non-Preferred: 50% coinsurance	Not covered		
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	10% coinsurance	20% coinsurance	------None------	
	Physician/surgeon fees	10% coinsurance	20% coinsurance	------None------	
If you need immediate medical attention	Emergency room care	$75 copay per date
of service for facility
and physician(s) combined	$75 copay per date
of service for facility
and physician(s) combined	For emergency medical conditions treated out-of-network, you may be balance billed.	
	Emergency medical transportation	No charge	0% coinsurance	For covered non-emergent situations, out-of-network ambulance services are NOT reimbursed at the in-network level. The member may be balance billed for any out-ofnetwork service.	
	Urgent care	$15 copay per date of service	20% coinsurance	------None------	
If you have a hospital stay	Facility fee (e.g., hospital room)	10% coinsurance	20% coinsurance	Reduction for failure to precertify out-of-network services is 50% and will not exceed $500 per admission.	
	Physician/surgeon fees	10% coinsurance	20% coinsurance	------None------	

Common
Medical Event	Services You May Need	What You Will Pay
In-Network (IN)
Provider
(You will pay the least)	What You Will Pay
Out-of-Network
(OON) Provider
(You will pay the most)	Limitations, Exceptions, & Other Important
Information	
If you need mental health, behavioral health, or substance abuse services	Outpatient services	Office: $15 copay per date of service Facility: 10% coinsurance	20% coinsurance	------None------	
	Inpatient services	10% coinsurance	20% coinsurance	Reduction for failure to precertify out-of-network services is 50% and will not exceed $500 per admission.	
If you are pregnant	Office visits	$200 copay per date of service for physician services	20% coinsurance	Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Cost sharing does not apply to certain preventive services. For any innetwork services that fall outside of routine obstetric care, the office visit benefits shown above may apply.	
	Childbirth/delivery professional services	$200 copay per date of service for physician services	20% coinsurance	Benefits shown reflect OB/GYN practitioner services which are typically globally billed at time of delivery for pre-natal, post-natal and delivery services.	
	Childbirth/delivery facility services	10% coinsurance	20% coinsurance	------None------	

Common
Medical Event	Services You May Need	What You Will Pay
In-Network (IN)
Provider
(You will pay the least)	What You Will Pay
Out-of-Network
(OON) Provider
(You will pay the most)	Limitations, Exceptions, & Other Important
Information	
If you need help recovering or have
other special health
needs	Home health care	10% coinsurance	20% coinsurance	Reduction for failure to precertify is 50% per covered service.	
	Rehabilitation services	Office: $15 copay per date of service Facility: 10% coinsurance	20% coinsurance	------None------	
	Habilitation services	Office: $15 copay per date of service Facility: 10% coinsurance	20% coinsurance	------None------	
	Skilled nursing care	10% coinsurance	20% coinsurance	Limit of 90 days per calendar year. Reduction for failure to precertify out-of-network services is 50% and will not exceed $500 per admission.	
	Durable medical equipment	10% coinsurance	20% coinsurance	------None------	
	Hospice services	10% coinsurance	20% coinsurance	Hospice respite care is limited to 15 inpatient and 15 outpatient days per lifetime.	
If your child needs dental or eye care	Children’s eye exam	Not covered	Not covered	------None------	
	Children’s glasses	Not covered	Not covered	------None------	
	Children’s dental check-up	Not covered	Not covered	------None------	

Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)	
•	Acupuncture	• Glasses
•	Cosmetic surgery	• Hearing aids
•	Custodial care - in home or facility	• Long-term care
•	Dental care - Adult	• Routine eye care - Adult
•	Dental check-up	• Routine foot care
•	Extended home skilled nursing	• Some pharmacy drugs are not covered
•	Eye exam	• Weight loss programs	
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)	
•	Applied Behavior Analysis therapy-covered	• Most coverage provided outside the U.S. subject to state mandate through age 18 subject to • Private-duty nursing -
	annual limits	short term intermittent home skilled nursing
•	Bariatric surgery
•	Chiropractic care
•	Infertility treatment ($25,000 lifetime maximum)	
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the U.S. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, you can contact: Wellmark at 1-800-524-9242 or the Iowa Insurance Division at 515-281-5705.
Does this plan provide Minimum Essential Coverage? Yes
If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.
Does this plan meet the Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
 To see examples of how this plan might cover costs for a sample medical situation, see the next page. 
Wellmark Blue Cross and Blue Shield of Iowa is an Independent Licensee of the Blue Cross and Blue Shield Association.
This contains only a partial description of the benefits, limitations, exclusions and other provisions of the health care plan. It is not a contract or policy. It is a general overview only. It does not provide all the details of coverage, including benefits, exclusions, and policy limitations. In the event there are discrepancies between this document and the Coverage Manual, Certificate, or Policy, the terms and conditions of the Coverage Manual, Certificate, or Policy will govern.
About These Coverage Examples:
	This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.	
Peg is Having a Baby
(9 months of in-network pre-natal care and a hospital delivery)		Managing Joe's type 2 Diabetes
(a year of routine in-network care of a well-controlled condition)	

■ The plan's overall deductible	$3,000
■ PCP copayment	$15
■ Hospital(facility) coinsurance	10%
■ Other copayment	$200
This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)	■ The plan's overall deductible	$3,000
■ Specialist copayment	$15
■ Hospital(facility) coinsurance	10%
■ Other coinsurance	10%
This EXAMPLE event includes services like: Primary care physician office visits (including disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)	
Total Example Cost	$12,800		Total Example Cost	$7,400	
In this example, Peg would pay:	In this example, Joe would pay:
Cost Sharing		Cost Sharing	
Deductibles	$3,000		Deductibles	$90	
Copayments	$80		Copayments	$800	
Coinsurance	$900		Coinsurance	$0	
What isn’t covered		What isn’t covered	
Limits or exclusions	$60		Limits or exclusions	$200	
The total Peg would pay is	$4,040		The total Joe would pay is	$1,090	

Mia's Simple Fracture
(in-network emergency room visit and follow up care)
■ The plan's overall deductible	$3,000
■ Specialist copayment	$15
■ Hospital(facility) copayment	$75
■ Other coinsurance	10%
This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
Total Example Cost	$1,900	
In this example, Mia would pay:
Cost Sharing		
Deductibles		$200	
Copayments		$200	
Coinsurance		$0	
What isn’t covered		
Limits or exclusions		$0	
The total Mia would pay is		$400	

The amounts shown in the maternity claim example above are based on amounts using a single per person deductible. Some plans may actually apply a two-person or family deductible to maternity services for the mother and newborn baby.
The plan would be responsible for the other costs of these EXAMPLE covered services.

Required Federal Accessibility and Nondiscrimination Notice
Discrimination is against the law
Wellmark complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Wellmark does not exclude people or treat them differently because of their race, color, national origin, age, disability or sex.
Wellmark provides:
•	Free aids and services to people with disabilities so they may communicate effectively with us, such as:
•	Qualified sign language interpreters
•	Written information in other formats (large print, audio, accessible electronic formats, other formats)
•	Free language services to people whose primary language is not English, such as: • Qualified interpreters
•	Information written in other languages If you need these services, call 800-524-9242.

If you believe that Wellmark has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: Wellmark Civil Rights Coordinator, 1331 Grand Avenue, Station 5W189, 
Des Moines, IA 50309-2901, 515-376-4500, TTY 888-781-4262, Fax 515-376-9073, Email CRC@Wellmark.com. You can file a grievance in person, by mail, fax or email. If you need help filing a grievance, the Wellmark Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail, phone or fax at: U.S. Department of Health and Human Services, 200 Independence Avenue S.W., Room 509F, HHH Building, Washington DC 20201, 800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/ index.html.

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w>'k;oh.ng= erh>uwdRunDusdm< usdmw>rRpXRw>zH;w>rRwz.< vXwb.vXmbl;vJ< td.vXe*D>vDRI qJ;usd;ql 800=524=9242rhwrh> (TTY: 888=781=4262) wuh>I
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Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Health Plan of Iowa, Inc., Wellmark Synergy Health, Inc., Wellmark Value Health Plan, Inc. 
and Wellmark Blue Cross and Blue Shield of South Dakota are independent licensees of the Blue Cross and Blue Shield Association.
M-2318376 09/16 A