Women’s Health and Cancer Rights Act Notice 
This notice is being provided on behalf of the following entities: 
Wellmark, Inc. doing business as Wellmark Blue Cross and Blue Shield of Iowa 
Wellmark Health Plan of Iowa, Inc. 
Women’s Health and Cancer Rights Act (WHCRA) 
This notice informs you of the federal regulation that requires all health plans that cover mastectomies to also cover reconstruction of the removed breast. 
For members receiving mastectomy-related benefits, coverage will be provided, in a manner determined in consultation with the attending physician and patient, for: 
• All stages of reconstruction of the breast on which the mastectomh was preformed; 
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; 
• Prostheses; and 
• Treatment of physical complications of the mastectomy, including lymphedema. 
These benefits will be provided subject to the same deductible and coinsurance applicable to other medical and surgical benefits provided under this plan. 
If you have any questions or concerns, please contact the Customer Service phone number listed on your Wellmark identification card. 
Wellmark Blue Cross and Blue Shield of Iowa Wellmark Health Plan of Iowa, Inc. PO Box 9232 Des Moines. IA 50306-9232 
B-2301 8/16 AN-T 
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. 
ATENCIÓN: Si habla español, los servicios de asistencia de idiomas se encuentran disponibles gratuitamente para usted. Comuníquese al 800-524-9242 o al (TTY: 888-781-4262). 
注意: 如果您说普通话, 我们可免费为您提供语言协助服务。 请拨打 800-524-9242 或 (听障专线: 888-781-4262)。 
CHÚ Ý: Nếu quý vị nói tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ miễn phí có sẵn cho quý vị. Xin hãy liên hệ 800-524-9242 hoặc (TTY: 888-781-4262). 
NAPOMENA: Ako govorite hrvatski, dostupna Vam je besplatna podrška na Vašem jeziku. Kontaktirajte 800-524-9242 ili (tekstualni telefon za osobe oštećena sluha: 888-781-4262). 
ACHTUNG: Wenn Sie deutsch sprechen, stehen Ihnen kostenlose sprachliche Assistenzdienste zur Verfügung. Rufnummer: 800-524-9242 oder (TTY: 888-781-4262). 
مقرلاب لصتا .ةيناجملا ،ةيوغللا ةدعاسملا تامدخ كل رفون اننإف ،ةيبرعلا ةغللا ثدحتت تنك اذإ :هيبنت .(888-781-4262 : يصنلا فتاهلا ةمدخ( وأ 800-524-9242 
ສງຄວນເອາໃຈໃສ, ພາສາລາວ ຖາທານເວາ: ພວກເຮາມບລການຄວາມຊວຍເຫອດານພາ ສາໃຫທານໂດຍບເສຍຄາ ຫ 800-524-9242 ຕດຕທ. (TTY: 888-781-4262.) 
주의: 한국어 를 사용하시는 경우, 무료 언어 지원 서비스를 이용하실 수 있습니다. 800-524-9242번 또는 (TTY: 888-781-4262)번으로 연락해 주십시오. 
ध्यान रख : अगर आपकी भयाषया हिन्दी ि, तो आपक हिए भयाषया सिया्तया सवयाए, हनःशलक उपिब्ध ि। 800-524-9242 पर सपक कर ्या (TTY: 888-781-4262)। 
ATTENTION : si vous parlez français, des services d’assistance dans votre langue sont à votre disposition gratuitement. Appelez le 800 524 9242 (ou la ligne ATS au 888 781 4262). 
Geb Acht: Wann du Deitsch schwetze duscht, kannscht du Hilf in dei eegni Schprooch koschdefrei griege. Ruf 800-524-9242 odder (TTY: 888-781-4262) uff. 
โปรดทราบ: หากคณพด ไทย เรามบรการชวยเหลอดานภาษาสาหรบคณโดยไม คดคาใชจาย ตดตอ 800-524-9242 หรอ (TTY: 888-781-4262) 
PAG-UKULAN NG PANSIN: Kung Tagalog ang wikang ginagamit mo, may makukuha kang mga serbisyong tulong sa wika na walang bayad. Makipag-ugnayan sa 800-524-9242 o (TTY: 888-781-4262). 
w>'k;oh.ng=erh>uwdRunDusdm<usdmw>rRpXRw>zH;w>rRwz.<vXwb.vXmbl;vJ<td.vXe*D>vDRI qJ;usd;ql800=524=9242rhwrh>(TTY:888=781=4262)wuh>I 
ВНИМАНИЕ! Если ваш родной язык русский, вам могут быть предоставлены бесплатные переводческие услуги. Обращайтесь 800-524-9242 (телетайп: 888-781-4262(. 
सयाव्धयान: ्द् तपयाईं नपयािदी बोलनहुन्छ भन, तपयाईंकया ियाहग हन:शलक रूपमया भयाषया सिया्तया सवयािरू उपिब्ध गरयाइन्छ । 800-524-9242 वया (TTY: 888-781-4262) मया समपक गनिोस । 
ማሳሰቢያ፦ አማርኛ የሚናገሩ ከሆነ፣ የቋንቋ እገዛ አገልግሎቶች፣ ከክፍያ ነፃ፣ ያገኛሉ። በ 800-524-9242 ወይም (በTTY: 888-781-4262) ደውለው ያነጋግሩን። 
HEETINA To a wolwa Fulfulde laabi walliinde dow wolde, naa e njobdi, ene ngoodi ngam maaɗa. Heɓir 800-524-9242 malla (TTY: 888-781-4262). 
FUULEFFANNAA: Yo isin Oromiffaa, kan dubbattan taatan, tajaajiloonni gargaarsa afaanii, kaffaltii malee, isiniif ni jiru. 800-524-9242 yookin (TTY: 888-781-4262) quunnamaa. 
УВАГА! Якщо ви розмовляєте українською мовою, для вас доступні безкоштовні послуги мовної підтримки. Зателефонуйте за номером 800-524-9242 або (телетайп: 888-781-4262). 
Ge’: Diné k’ehj7 y1n7[ti’go n7k1 bizaad bee 1k1’ adoowo[, t’11 jiik’4, n1h0l=. Koj8’ h0lne’ 800-524-9242 doodaii’ (TTY: 888-781-4262) 
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 08/16 A