Merit Health Insurance Benefit Comparison - Effective 2017

Plan Provisions Comparison
Provisions Wellmark Blue Access BC/BS
Iowa Select
BC/BS
Program III Plus
Care Providers Care from network providers ONLY; Life-threatening emergencies covered anywhere Any provider; network providers have lower co-insurance percentage and deductible is waived for services in the office setting Any provider; BlueCross/BlueShield (BC/BS) providers can result in lower out-of-pocket expenses
Benefits Available from Non-member Providers None without prior approval Normal plan benefits; For non-BC/BS providers, employee pays charges over usual reasonable and customary limit Normal plan benefits; For non-BC/BS providers, employee pays charges over usual reasonable and customary limit
Deductible Single/Family None $250 / $500; Deductible is waived for Select providers only if service is in office setting $300 single contract/ $400 family contract for inpatient services only
Co-insurance Percentage 10% Network: 10%;
Non-Network: 20%
20%
Out-of-Pocket Limit
Single/Family
$750 / $1500
($5,850/$11,700 for prescription drugs)
$1000 / $2000
($500 / $1000 for prescription drugs)
$1000 / $2000
($500 / $1000 for prescription drugs)
Pre-approval of Inpatient Admissions Required (Plan physician will determine) Required (Subscriber must obtain approval from BC/BS) Required (Subscriber must obtain approval from BC/BS)
Second Surgical Opinion Voluntary Voluntary Voluntary
Outpatient Surgery 10% Network: 10%, deductible waived;
Non-Network 20% after deductible
0%, no deductible
Office Visit $10 co-payment per visit Network: $15 co-payment per visit and 10%, deductible waived;
Non-Network: 20% after deductible
$15 co-payment per visit and 20%
Routine Physicals 0% per ACA guidelines 0% per ACA guidelines 0% per ACA guidelines
Radiology (Office) $10 Network: 10%; Deductible waived if in office setting
Non-Network: deductible then 20%
Related to the surgery: 0%, deductible waived;
Non-surgery related: 20%
Outpatient Diagnostic Lab and Radiology 10% Network 10% after deductible
Non-Network: 20% after deductible
20%, no deductible
Routine Eye /
Hearing Exam
$10 co-payment;
One exam covered per calendar year
Limit one exam per year; $15 co-pay Not covered
Maternity $10 co-payment for initial visit $15 co-pay; Once per date of service for exam only. Other office services: Network 10%, deductible waived.
Non-Network 20%, after deductible
$15 co-pay exam only Other office services: 20%, no deductible
Infertility Not covered Network: 10%;
Non-Select: deductible then 20%;
$25,000 lifetime maximum
20%;
$25,000 lifetime maximum
Hospital Services Comparison
Hospital Services Wellmark Blue Access BC/BS
Iowa Select
BC/BS
Program Three Plus
Room and Board 10% Network: 10% after deductible;
Non-Network: 20% after deductible
20% after inpatient services deductible $300/$400
Physicians’ Services 10% if authorized Network: deductible then 10%;
Non-Network: deductible then 20%
20% after deductible
Inpatient Surgery 10% if authorized Network: deductible then 10%;
Non-Network: deductible then 20%
20%; No deductible;
Must be approved as inpatient procedures.
Inpatient Supplies, Drugs, Medicines, Tests, ICU, OR, Specialized Care, etc. 10% if authorized Network: deductible then 10%;
Non-Network: deductible then 20%
20% after deductible
Miscellaneous Services Comparison
Services Wellmark Blue Access BC/BS
Iowa Select
BC/BS
Program Three Plus
Prescription Drugs
(30 day supply)
$5 co-payment preferred generic drugs;
$15 co-payment preferred brand name drugs;
$30 or 25% co-payment non-preferred drugs;
Separate $5850/$11,700 out-of-pocket maximum
$5 co-payment preferred generic drugs;
$15 co-payment preferred brand name drugs;
$30 co-payment non-preferred drugs;
Separate $500/$1000 out-of-pocket maximum
$5 co-payment preferred generic drugs;
$15 co-payment preferred name brand drugs;
$30 co-payment non-preferred drugs;
Separate $500/$1000 out-of-pocket maximum
Allergy Treatments $10 co-payment per visit Network: 10%;
Non-Network: deductible then 20%
20%
Chiropractor $10 co-payment per visit;
Prior approval may be required
$15 copay exam only
Network: 10%, deductible waived;
Non-Network: deductible then 20%
$15 copay for exam only
20%, no deductible
Eyeglasses /
Hearing Aids
Not covered Not covered Not covered
Ambulance 10% Network: 10% after deductible
Non-network: Deductible then 20%
20%, no deductible
ER Care $50 co-payment per visit (waived if admitted) even if OPM has been met $50 co-payment per visit (waived if admitted) and 10% co-insurance 0%, no deductible
Physical Therapy $10 co-payment per visit;
60 visit maximum
Network: deductible then 10%;
Non-Network: deductible then 20%
20%
Speech, Occupational, and Respiratory Therapy $10 co-payment;
60 visit maximum (of each type);
Prior approval required
Network: deductible then 10%;
Pre-approval required; Non-Network: deductible then 20%;
Pre-approval required
20%;
Pre-approval required;
Must be hospital-based billed
Dependent Child Age Limit End of the year they turn 26; unlimited if a full time single student or disabled before age 27 End of the year they turn 26; unlimited if a full time single student or disabled before age 27 End of the year they turn 26; unlimited if a full time single student or disabled before age 27
Mental, Nervous, and Substance Abuse Comparison
Services Wellmark Blue Access BC/BS
Iowa Select
BC/BS
Program Three Plus
Inpatient Hospital Room and Board 10% Network: deductible then 10%;
Non-Network: deductible then 20%
20% after deductible
Office Visit $10 copay $15 copay $15 copay
Outpatient 0% co-payment 0% 0%
Pre-certification Required Required Required

This website provides a general summary of the basic benefit provisions and is not a substitute for the Benefit Booklet. If there are any inconsistencies between this summary and the benefit booklet, the booklet will prevail. Please refer to the Benefit Booklet for exact benefits, exclusions, and limitations or contact Wellmark’s customer service at 1-800-622-0043.