Coverage Manual

COVERAGE MANUAL

Sample Group Name

Group Effective Date: 1/1/2021 Plan Year: January 1 Print Date: 2/8/2021 Coverage Code: CHRXST Form Number: Wellmark IA Grp Version: 01/21

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NOTICE OF PROTECTION PROVIDED BY IOWA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION This notice provides a brief summary of the Iowa Life and Health Insurance Guaranty Association (the “Association”) and the protection it provides for policyholders. This safety net was created under Iowa law, which determines who and what is covered and the amounts of coverage. The Association was established to provide protection in the unlikely event that your life, annuity or health insurance company becomes financially unable to meet its obligations and is taken over by its Insurance Department. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Iowa law, with funding from assessments paid by other insurance companies. The basic protections provided by the Association are: Life Insurance ◼ $300,000 in death benefits ◼ $100,000 in cash surrender and withdrawal values Health Insurance ◼ $500,000 in basic hospital, medical-surgical or major medical insurance benefits ◼ $300,000 in disability income protection insurance benefits ◼ $300,000 in long-term care insurance benefits ◼ $100,000 in other types of health insurance benefits Annuities ◼ $250,000 in annuity benefits, cash surrender and withdrawal values The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $350,000. Special rules may apply with regard to hospital, medical-surgical and major medical insurance benefits. Note: Certain policies and contracts may not be covered or fully covered. If coverage is available, it will be subject to substantial limitations and exclusions. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also various residency requirements under Iowa law. To learn more about the Association and the protections it provides, as well as those relating to group contracts or retirement plans, please visit the Association's website at www.ialifega.org, or contact: Iowa Life and Health Insurance Iowa Insurance Division Guaranty Association 1963 Bell Avenue, Suite 100 700 Walnut Street, Suite 1600 Des Moines, IA 50315 Des Moines, IA 50309 (515) 664-6600 (515) 248-5712 Information about the financial condition of insurers is available from a variety of sources, including financial rating agencies such as AM Best Company, Fitch Inc., Moody's Investors Service, Inc., and Standard & Poor's. That information may be accessed from the “Helpful Links & Information” page located on the website of the Iowa Insurance Division at www.iid.iowa.gov. The Association is subject to supervision and regulation by the Commissioner of the Iowa Insurance Division. Persons who desire to file a complaint to allege a violation of the laws governing the Association may contact the Iowa Insurance Division. State law provides that any suit against the Association shall be brought in the Iowa District Court in Polk County, Iowa. Insurance companies and agents are not allowed by Iowa law to use the existence of the Association or its coverage to encourage you to purchase any form of insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and Iowa law, then Iowa law will control.

Contents

About This Coverage Manual ...... 1 1. What You Pay ...... 3 Payment Summary ...... 4 Payment Details ...... 5 2. At a Glance - Covered and Not Covered ...... 11 Medical ...... 11 Prescription Drugs ...... 14 3. Details - Covered and Not Covered ...... 15 Medical ...... 15 Prescription Drugs ...... 32 4. General Conditions of Coverage, Exclusions, and Limitations ...... 37 Conditions of Coverage...... 37 General Exclusions ...... 38 Benefit Limitations ...... 40 5. Choosing a Provider ...... 43 Medical ...... 43 Prescription Drugs ...... 51 6. Notification Requirements and Care Coordination ...... 53 Medical ...... 53 Prescription Drugs ...... 57 7. Factors Affecting What You Pay ...... 59 Medical ...... 59 Prescription Drugs ...... 63 8. Coverage Eligibility and Effective Date ...... 67 Eligible Members ...... 67 When Coverage Begins ...... 68 Late Enrollees ...... 68 Changes to Information Related to You or to Your Benefits ...... 68 Qualified Medical Child Support Order ...... 68 9. Coverage Changes and Termination ...... 71 Coverage Change Events ...... 71 Requirement to Notify Group Sponsor ...... 72 Coverage Termination...... 72 Coverage Continuation ...... 73 10. Claims...... 75 When to File a Claim ...... 75 How to File a Claim ...... 75 Notification of Decision...... 76 11. Coordination of Benefits ...... 79 Other Coverage ...... 79 Claim Filing ...... 79 Rules of Coordination ...... 80 Coordination with Medicare ...... 83

12. Appeals ...... 85 Right of Appeal ...... 85 How to Request an Internal Appeal ...... 85 Where to Send Internal Appeal ...... 85 Review of Internal Appeal ...... 85 Decision on Internal Appeal ...... 86 External Review ...... 86 Arbitration and Legal Action ...... 87 13. Arbitration and Legal Action ...... 89 Mandatory Arbitration ...... 89 Covered Claims ...... 89 No Class Arbitrations and Class Actions Waiver ...... 89 Claims Excluded from Mandatory Arbitration ...... 89 Arbitration Process Generally ...... 90 Arbitration Fees and Other Costs ...... 91 Confidentiality ...... 91 Questions of Arbitrability ...... 91 Claims Excluded By Applicable Law ...... 91 Survival and Severability of Terms ...... 91 14. Your Rights Under ERISA ...... 93 15. General Provisions ...... 95 Contract ...... 95 Interpreting this Coverage Manual ...... 95 Plan Year ...... 95 Authority to Terminate, Amend, or Modify ...... 95 Authorized Group Benefits Plan Changes ...... 95 Member Participation ...... 95 Authorized Representative ...... 95 Release of Information ...... 96 Privacy of Information ...... 96 Member Health Support Services ...... 97 Value Added or Innovative Benefits ...... 97 Value-Based Programs ...... 97 Nonassignment ...... 97 Governing Law ...... 97 Medicaid Enrollment and Payments to Medicaid ...... 98 Subrogation ...... 98 Workers’ Compensation ...... 100 Payment in Error ...... 100 Premium ...... 100 Notice ...... 101 Inspection of Coverage ...... 101 Submitting a Complaint ...... 101 Consent to Telephone Calls and Text or Email Notifications...... 101 Glossary ...... 103 Index ...... 107

About This Coverage Manual

Contract This coverage manual describes your rights and responsibilities under your group health plan. You and your covered dependents have the right to request a copy of this coverage manual, at no cost to you, by contacting your employer or group sponsor. Please note: Your employer or group sponsor has the authority to terminate, amend, or modify the coverage described in this coverage manual at any time. Any amendment or modification will be in writing and will be as binding as this coverage manual. If your contract is terminated, you may not receive benefits. You should familiarize yourself with the entire manual because it describes your benefits, payment obligations, provider networks, claim processes, and other rights and responsibilities. This group health plan consists of medical benefits and prescription drug benefits. Your Wellmark Health Plan of Iowa, Inc., (Wellmark) point-of-service (POS) benefits are called Blue Choice. The prescription drug benefits are called Blue Rx Complete. This coverage manual will indicate when the service, supply or drug is considered medical benefits or drug benefits by using sections, headings, and notes when necessary. Charts Some sections have charts, which provide a quick reference or summary but are not a complete description of all details about a topic. A particular chart may not describe some significant factors that would help determine your coverage, payments, or other responsibilities. It is important for you to look up details and not to rely only upon a chart. It is also important to follow any references to other parts of the manual. (References tell you to “see” a section or subject heading, such as, “See Details – Covered and Not Covered.” References may also include a page number.) Complete Information Very often, complete information on a subject requires you to consult more than one section of the manual. For instance, most information on coverage will be found in these sections:

◼ At a Glance – Covered and Not Covered ◼ Details – Covered and Not Covered ◼ General Conditions of Coverage, Exclusions, and Limitations However, coverage might be affected also by your choice of provider (information in the Choosing a Provider section), certain notification requirements if applicable to your group health plan (the Notification Requirements and Care Coordination section), and considerations of eligibility (the Coverage Eligibility and Effective Date section). Even if a service is listed as covered, benefits might not be available in certain situations, and even if a service is not specifically described as being excluded, it might not be covered. Read Thoroughly You can use your group health plan to the best advantage by learning how this document is organized and how sections are related to each other. And whenever you look up a particular topic, follow any references, and read thoroughly.

Form Number: Wellmark IA Grp/AM_ 0121 1 CHRXST About This Coverage Manual

Your coverage includes many services, treatments, supplies, devices, and drugs. Throughout the coverage manual, the words services or supplies refer to any services, treatments, supplies, devices, or drugs, as applicable in the context, that may be used to diagnose or treat a condition. Questions If you have questions about your group health plan, or are unsure whether a particular service or supply is covered, call the Customer Service number on your ID card.

CHRXST 2 Form Number: Wellmark IA Grp/AM_ 0121

1. What You Pay

This section is intended to provide you with an overview of your payment obligations under this group health plan. This section is not intended to be and does not constitute a complete description of your payment obligations. To understand your complete payment obligations you must become familiar with this entire coverage manual, especially the Factors Affecting What You Pay and Choosing a Provider sections. Provider Network Under the medical benefits of this plan, your network of providers consists of Wellmark Blue POSSM and Participating providers, including your designated personal doctor. All other providers are not in your network. Which provider type you choose will affect what you pay. Designated Personal Doctor. Your designated personal doctor, which may also be referred to as your designated PCP, evaluates your medical condition and either treats your condition or coordinates services you require. You must choose a personal doctor who participates in the Wellmark Blue POS network, who is available to accept you or your family members, and who is one of the following types of providers: family practitioners, general practitioners, internists, nurse practitioners, physician assistants, and pediatricians.

Medical Benefit Levels Your Blue Choice medical program is unique because you have the flexibility to go to almost any provider you choose. However, how you access care affects what you pay. Benefit Level 1 applies when:

◼ You receive care from your designated personal doctor or a Wellmark Blue POS network facility. ◼ You receive maternity care or your preventive gynecological examination from your selected OB/GYN. ◼ You receive covered immunizations from a Wellmark Blue POS Public Health Agency or Wellmark Blue POS Visiting Nurse Association. ◼ You receive influenza and pneumonia immunizations from a covered Wellmark Blue POS specialist. ◼ You receive routine vision examinations from a Wellmark Blue POS optometrist or Wellmark Blue POS ophthalmologist. ◼ You receive covered chiropractic services from a Wellmark Blue POS chiropractor. ◼ You receive covered occupational therapy services from a Wellmark Blue POS occupational therapist. ◼ You receive covered physical therapy services from a Wellmark Blue POS physical therapist. ◼ You receive covered speech therapy services from a Wellmark Blue POS speech pathologist. Benefit Level 2 in general applies when you receive services from a Wellmark Blue POS Provider but not from your designated personal doctor or you receive services from a Participating or Out-of-Network provider with a Wellmark-approved referral. Benefit Level 3 in general applies when you receive services from a Participating or Out-of- Network provider without a Wellmark-approved referral.

Form Number: Wellmark IA Grp/WYP_ 0121 3 CHRXST What You Pay

Payment Summary This chart summarizes your payment responsibilities. It is only intended to provide you with an overview of your payment obligations. It is important that you read this entire section and not just rely on this chart for your payment obligations. You Pay Deductible $500 per person for covered services received at Benefit Level 1 or 2. $1,000 (maximum) per family* for covered services received at Benefit Level 1 or 2. $750 per person for covered services received at Benefit Level 3. $1,500 (maximum) per family* for covered services received at Benefit Level 3. Emergency Room Copayment $50 Office Visit Copayment $25 for covered services received at Benefit Level 1. $40 for covered services received at Benefit Level 2. Telehealth Services Copayment $20 for covered telehealth services received from practitioners contracting through Doctor on Demand§. $25 for covered telehealth services received at Benefit Level 1. $40 for covered telehealth services received at Benefit Level 2. Coinsurance 10% for covered services received at Benefit Level 1 or 2. 20% for covered services received at Benefit Level 3. Out-of-Pocket Maximum $2,000 per person for covered services received from Wellmark Blue POS and Participating providers. This includes amounts you pay for covered drugs. $4,000 (maximum) per family* for covered services received from Wellmark Blue POS and Participating providers. This includes amounts you pay for covered drugs. $4,000 per person for covered services received from Out-of-Network Providers without a referral. $8,000 (maximum) per family* for covered services received from Out-of-Network Providers without a referral. *Family amounts are reached from amounts accumulated on behalf of any combination of covered family members. A member will not be required to satisfy more than the single deductible before we make benefit payments for that member. §Members can access telehealth services from Doctor on Demand through the Doctor on Demand mobile application. Please note: Out-of-pocket maximum amounts you pay for covered medical benefits under Blue Choice also apply toward the Blue Rx Complete out-of-pocket maximum. Likewise, out-of-pocket maximum amounts you pay for covered prescription drug benefits under Blue Rx Complete apply toward the Blue Choice medical out-of-pocket maximum.

Prescription Drugs

You Pay† Coinsurance or Copayment $10 for Tier 1 medications. $25 for Tier 2 medications. $40 for Tier 3 medications. $80 for Tier 4 medications. For more information see Tiers, page 63. $50 for preferred biosimilar and generic specialty drugs. $100 for preferred brand specialty drugs. 50% for non-preferred specialty drugs. 10% for pharmacy durable medical equipment devices.

CHRXST 4 Form Number: Wellmark IA Grp/WYP_ 0121 What You Pay

You Pay† Out-of-Pocket Maximum $500 per person $1,000 (maximum) per family* *Family amounts are reached from amounts accumulated on behalf of any combination of covered family members. †You pay the entire cost if you purchase a drug or pharmacy durable medical equipment device that is not on the Wellmark Blue Rx Complete Drug List. See Wellmark Blue Rx Complete Drug List, page 33. Please note: Out-of-pocket maximum amounts you pay for covered prescription drug benefits under Blue Rx Complete apply toward the Blue Choice medical out-of-pocket maximum. Likewise, out-of-pocket maximum amounts you pay for covered medical benefits under Blue Choice also apply toward the Blue Rx Complete out-of-pocket maximum. Prescription Maximums Generally, there is a maximum days' supply of medication you may receive in a single prescription. However, exceptions may be made for certain prescriptions packaged in a dose exceeding the maximum days' supply covered under your Blue Rx Complete prescription drug benefits. To determine if this exception applies to your prescription, call the Customer Service number on your ID card. Your payment obligations may be determined by the quantity of medication you purchase. Payment 90 day retail Payment per days' supply: 1 copayment for 30 day supply 2 copayments for 60 day supply 3 copayments for 90 day supply 90 day mail order Payment per days' supply: 1 copayment for 30 day supply 2 copayments for 60 day supply 3 copayments for 90 day supply 30 day specialty 1 copayment or coinsurance, as applicable Payment Details

Medical both the Benefit Level 1 and 2 deductible Deductible and the Benefit Level 3 deductible. The This is a fixed dollar amount you pay for maximum deductible amount you pay is the covered services in a benefit year before Benefit Level 3 deductible. medical benefits become available. Once you meet the deductible, then The family deductible amount is reached coinsurance applies. from amounts accumulated on behalf of any Deductible amounts you pay during the last combination of covered family members. three months of a benefit year carry over as A member will not be required to satisfy credits to meet your deductible for the next more than the single deductible before we benefit year. These credits do not apply make benefit payments for that member. toward your out-of-pocket maximum. Deductible amounts you pay for covered Common Accident Deductible. When services received at Benefit Level 1 and 2 or two or more covered family members are at Benefit Level 3 apply toward meeting involved in the same accident and they

Form Number: Wellmark IA Grp/WYP_ 0121 5 CHRXST What You Pay receive covered services for injuries related Copayment amount(s) are waived for some to the accident, only one deductible amount services. See Waived Payment Obligations will be applied to the accident-related later in this section. services for all family members involved. However, you still need to satisfy the family Coinsurance (not the per person) out-of-pocket Coinsurance is an amount you pay for maximum. certain covered services. Coinsurance is Deductible amounts are waived for some calculated by multiplying the fixed services. See Waived Payment Obligations percentage(s) shown earlier in this section later in this section. times Wellmark’s payment arrangement amount. Payment arrangements may differ Copayment depending on the contracting status of the provider and/or the state where you receive This is a fixed dollar amount that you pay services. For details, see How Coinsurance each time you receive certain covered is Calculated, page 59. Coinsurance services. amounts apply after you meet the Emergency Room Copayment. deductible. The emergency room copayment: Coinsurance amounts are waived for some services. See Waived Payment Obligations ◼ applies to emergency room services. later in this section. ◼ is taken once per visit. ◼ is waived if you are admitted as an Out-of-Pocket Maximum inpatient of a facility immediately The out-of-pocket maximum is the following emergency room services. maximum amount you pay, out of your Office Visit Copayment. pocket, for most covered services in a The office visit copayment: benefit year. Many amounts you pay for covered services during a benefit year ◼ applies to covered office services accumulate toward the out-of-pocket received from a Wellmark Blue POS maximum according to applicable provider Provider. This office visit copayment network cost sharing. These amounts also applies to: include: ⎯ annual vision examinations received from a Wellmark Blue POS ◼ Deductible. optometrist or Wellmark Blue POS ◼ Coinsurance. ophthalmologist. ◼ Emergency room copayments. Laboratory services received from an ◼ Office visit copayments. independent lab are subject to a ◼ Telehealth services copayments. separate office visit copayment. ◼ Amounts you pay for covered ◼ is taken once per practitioner per date of prescription drugs. service. The family out-of-pocket maximum is Telehealth Services Copayment. reached from applicable amounts paid on behalf of any combination of covered family The telehealth services copayment: members. ◼ applies to covered telehealth services A member will not be required to satisfy received from Wellmark Blue POS more than the single out-of-pocket practitioners and practitioners maximum. contracting through Doctor on Demand. ◼ is taken once per practitioner per date of Out-of-pocket maximum amounts you pay service. for covered medical benefits under Blue

CHRXST 6 Form Number: Wellmark IA Grp/WYP_ 0121 What You Pay

Choice also apply toward the Blue Rx ◼ Difference in cost between the generic Complete out-of-pocket maximum. drug and the brand name drug when Likewise, out-of-pocket maximum amounts you purchase a brand name drug that you pay for covered prescription drug has an FDA-approved “A”-rated benefits under Blue Rx Complete apply medically appropriate generic toward the Blue Choice medical out-of- equivalent. pocket maximum. These amounts continue even after you have There is an out-of-pocket maximum for met your out-of-pocket maximum. services you receive from Wellmark Blue POS Providers and Participating Providers. Benefits Maximums There is also an out-of-pocket maximum for Benefits maximums are the maximum services you receive from Out-of-Network benefit amounts that each member is Providers. These out-of-pocket maximums eligible to receive. accumulate to one another. Benefits maximums that apply per benefit However, certain amounts do not apply year or per lifetime are reached from toward your out-of-pocket maximum. benefits accumulated under this group health plan and any prior group health ◼ Amounts representing any general plans sponsored by your employer or group exclusions and conditions. See General sponsor and administered by Wellmark Conditions of Coverage, Exclusions, and Health Plan of Iowa, Inc. Limitations, page 37. Benefits maximums accumulate from ◼ Difference in cost between the provider’s amount charged and our maximum benefits provided at Benefit Level 1, 2, or 3 allowable fee when you receive services combined. from an Out-of-Network Provider.

Waived Payment Obligations Some payment obligations are waived for the following covered services. Covered Service Payment Obligation Waived Breast pumps (manual or non-hospital grade electric) purchased from Deductible a covered Wellmark Blue POS or Participating home/durable medical Coinsurance equipment provider. Copayment

Breastfeeding support, supplies, and one-on-one lactation consultant Deductible services, including counseling and education, during pregnancy and/or Coinsurance the duration of breastfeeding when received from Wellmark Blue POS Copayment or Participating providers.

Contraceptive medical devices, such as intrauterine devices and Deductible diaphragms received from Wellmark Blue POS or Participating Coinsurance providers. Copayment

Implanted and injected contraceptives received from Wellmark Blue Deductible POS or Participating providers. Coinsurance Copayment

Form Number: Wellmark IA Grp/WYP_ 0121 7 CHRXST What You Pay

Covered Service Payment Obligation Waived Medical evaluations and counseling for nicotine dependence per U.S. Deductible Preventive Services Task Force (USPSTF) guidelines when received Coinsurance from Wellmark Blue POS or Participating providers. Copayment

Newborn’s initial hospitalization, when considered normal newborn Deductible care – facility services received at any level and practitioner services received at Benefit Level 1.

Office and independent lab services received from Wellmark Blue POS Deductible Providers. Some lab testing performed in the office may be sent to a Coinsurance provider that is not a Wellmark Blue POS Provider for processing. When this happens, your deductible and coinsurance may apply.

Physician services related to maternity care received at Benefit Level 1 Deductible or 2. Coinsurance Copayment

Postpartum home visit (one).** Deductible Coinsurance

Preventive care, items, and services,* received from Wellmark Blue Deductible POS or Participating providers, as follows: Coinsurance Copayment ◼ Items or services with an “A” or “B” rating in the current recommendations of the United States Preventive Services Task Force (USPSTF); ◼ Immunizations as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (ACIP); ◼ Preventive care and screenings for infants, children, and adolescents provided for in guidelines supported by the Health Resources and Services Administration (HRSA); and ◼ Preventive care and screenings for women provided for in guidelines supported by the HRSA.***

Prosthetic limb devices received at Benefit Level 1 or 2. Deductible

Services subject to emergency room copayment amounts. Deductible Coinsurance

Services subject to office visit copayment amounts. Deductible Coinsurance

Services subject to telehealth services copayment amounts.‡ Deductible Coinsurance

CHRXST 8 Form Number: Wellmark IA Grp/WYP_ 0121 What You Pay

Covered Service Payment Obligation Waived Voluntary sterilization for female members received from Wellmark Deductible Blue POS or Participating providers. Coinsurance Copayment

X-ray or lab services performed in an outpatient department of a Deductible Wellmark Blue POS network facility when the x-ray or lab services are the only services billed and interpretations by Wellmark Blue POS practitioners when your practitioner sends you to the outpatient department of a Wellmark Blue POS network facility. The deductible is not waived for the following diagnostic imaging/studies and radiation therapy services including, but not limited to: CT (computerized tomography), MEG (magnetoencephalography), MRAs (magnetic resonance angiography), MRIs (magnetic resonance imaging), PET (positron emission tomography), nuclear medicine, ultrasounds, radiation therapy, diagnostic mammograms, and diagnostic testing.

*A complete list of recommendations and guidelines related to preventive services can be found at www.healthcare.gov. Recommended preventive services are subject to change and are subject to medical management. **If you have a newborn child, but you do not add that child to your coverage, your newborn child may be added to your coverage solely for the purpose of administering benefits for the newborn during the first 48 hours following a vaginal delivery or 96 hours following a cesarean delivery. If that occurs, a separate deductible and coinsurance may be applied to your newborn child unless your coverage specifically waives the deductible or coinsurance for your newborn child. ***Digital breast tomosynthesis (3D mammogram) may be subject to deductible, coinsurance, and copayments, as applicable. ‡ Members can access telehealth services from Doctor on Demand through the Doctor on Demand mobile application.

Prescription Drugs Wellmark Blue Rx Complete Drug List, Coinsurance or Copayment page 33. Coinsurance is the amount you pay, calculated using a fixed percentage of the Out-of-Pocket Maximum maximum allowable fee, each time a The out-of-pocket maximum is the covered non-preferred specialty drug maximum you pay in a given benefit year prescription or pharmacy durable medical toward the following amounts: equipment device is filled or refilled. ◼ Coinsurance. Copayment is a fixed dollar amount you pay ◼ Copayments. each time any other covered prescription is filled or refilled. The family out-of-pocket maximum is reached from applicable amounts paid on You pay the entire cost if you purchase a behalf of any combination of covered family drug or pharmacy durable medical equipment device that is not on the members. Wellmark Blue Rx Complete Drug List. See

Form Number: Wellmark IA Grp/WYP_ 0121 9 CHRXST What You Pay

A member will not be required to satisfy However, certain amounts do not apply more than the single out-of-pocket toward your out-of-pocket maximum. maximum. ◼ Amounts representing any general Out-of-pocket maximum amounts you pay exclusions and conditions. See General for covered prescription drug benefits under Conditions of Coverage, Exclusions, and Blue Rx Complete also apply toward the Limitations, page 37. Blue Choice medical out-of-pocket ◼ Difference in cost between the generic maximum. Likewise, out-of-pocket drug and the brand name drug when maximum amounts you pay for covered you purchase a brand name drug that medical benefits under Blue Choice apply has an FDA-approved “A”-rated toward the Blue Rx Complete out-of-pocket medically appropriate generic maximum. equivalent. These amounts continue even after you have met your out-of-pocket maximum.

Waived Payment Obligations Some payment obligations are waived for the following covered drugs or services. Covered Drug or Service Payment Obligation Waived Generic contraceptive drugs and generic contraceptive drug delivery Copayment devices (e.g., birth control patches). Payment obligations are also waived if you purchase brand name contraceptive drugs or brand name drug delivery devices when an FDA-approved medically appropriate generic equivalent is not available. Payment obligations are not waived if you purchase brand name contraceptive drugs or brand name contraceptive drug delivery devices when an FDA-approved medically appropriate generic equivalent is available.

Preventive items or services* as follows: Copayment

◼ Items or services with an “A” or “B” rating in the current recommendations of the United States Preventive Services Task Force (USPSTF); and ◼ Immunizations as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (ACIP).

Two smoking cessation attempts per calendar year, up to a 90-days' Copayment supply of covered drugs for each attempt, or a 180-days' supply total per calendar year.

*A complete list of recommendations and guidelines related to preventive services can be found at www.healthcare.gov. Recommended preventive items and services are subject to change and are subject to medical management.

CHRXST 10 Form Number: Wellmark IA Grp/WYP_ 0121

2. At a Glance - Covered and Not Covered

Medical Your coverage provides benefits for many services and supplies. There are also services for which this coverage does not provide benefits. The following chart is provided for your convenience as a quick reference only. This chart is not intended to be and does not constitute a complete description of all coverage details and factors that determine whether a service is covered or not. All covered services are subject to the contract terms and conditions contained throughout this coverage manual. Many of these terms and conditions are contained in Details – Covered and Not Covered, page 15. To fully understand which services are covered and which are not, you must become familiar with this entire coverage manual. Please call us if you are unsure whether a particular service is covered or not. The headings in this chart provide the following information: Category. Service categories are listed alphabetically and are repeated, with additional detailed information, in Details – Covered and Not Covered. Covered. The listed category is generally covered, but some restrictions may apply. Not Covered. The listed category is generally not covered. See Page. This column lists the page number in Details – Covered and Not Covered where there is further information about the category. Benefits Maximums. This column lists maximum benefit amounts that each member is eligible to receive. Benefits maximums that apply per benefit year or per lifetime are reached from benefits accumulated under this group health plan and any prior group health plans sponsored by your employer or group sponsor and administered by Wellmark Health Plan of Iowa, Inc.

Category Benefits Maximums

Covered NotCovered Page See

Acupuncture Treatment  15 Allergy Testing and Treatment ⚫ 15 Ambulance Services ⚫ 15 Anesthesia ⚫ 16 Autism Treatment ⚫ 16 Applied Behavior Analysis (ABA) services for the treatment of autism spectrum disorder for children age 18 and younger: ◼ For children through age six: $36,000 per calendar year. ◼ For children age seven through age 13: $25,000 per calendar year. ◼ For children age 14 through age 18: $12,500 per calendar year. Blood and Blood Administration ⚫ 17

Form Number: Wellmark IA Grp/AGC_ 0121 11 CHRXST At A Glance – Covered and Not Covered

Category Benefits Maximums

Covered NotCovered Page See

Chemical Dependency Treatment ⚫  17 Chemotherapy and Radiation Therapy ⚫ 17 Clinical Trials – Routine Care Associated ⚫ 17 with Clinical Trials  Contraceptives ⚫ 18 Conversion Therapy  18 Cosmetic Services  18 Counseling and Education Services ⚫  18 Dental Treatment for Accidental Injury ⚫ 18 19 Dialysis ⚫ Education Services for Diabetes and ⚫ 19 Nutrition Emergency Services ⚫ 20 Fertility and Infertility Services ⚫  20 Genetic Testing ⚫ 20 Hearing Services (related to an illness or ⚫ 20 injury) Home Health Services ⚫ 21 The daily benefit for short-term home skilled nursing services will not exceed Wellmark’s daily maximum allowable fee for skilled nursing facility services. Home/Durable Medical Equipment ⚫ 22 Hospice Services ⚫  22 15 days per lifetime for inpatient hospice respite care. 15 days per lifetime for outpatient hospice respite care. Please note: Hospice respite care must be used in increments of not more than five days at a time. Hospitals and Facilities ⚫ 22 90 days per benefit year of skilled nursing services in a hospital or nursing facility. Illness or Injury Services ⚫ 23 Inhalation Therapy ⚫ 23 Maternity Services ⚫ 23 Medical and Surgical Supplies and ⚫ 24 Personal Convenience Items Mental Health Services ⚫  25 Motor Vehicles  26 Musculoskeletal Treatment ⚫  26 Nonmedical or Administrative Services  26 Nutritional and Dietary Supplements ⚫ 26

CHRXST 12 Form Number: Wellmark IA Grp/AGC_ 0121 At A Glance – Covered and Not Covered

Category Benefits Maximums

Covered NotCovered Page See

Occupational Therapy ⚫ 26 Orthotics (Foot)  27 Physical Therapy ⚫ 27 Physicians and Practitioners 27 Advanced Registered Nurse ⚫  27 Practitioners Audiologists ⚫ 27 Chiropractors ⚫  27 Doctors of Osteopathy ⚫ 27 Licensed Independent Social Workers ⚫ 27 Medical Doctors ⚫ 27 Occupational Therapists ⚫ 27 Optometrists ⚫ 27 Oral Surgeons ⚫ 27 Physical Therapists ⚫ 27 Physician Assistants ⚫  27 Podiatrists ⚫ 27 Psychologists ⚫ 27 Speech Pathologists ⚫ 27 Prescription Drugs ⚫  28 Preventive Care ⚫  29 Well-child care until the child reaches age seven. One routine physical examination per benefit year. One routine mammogram per benefit year. One routine gynecological examination per benefit year. One routine Pap smear per benefit year. Prosthetic Devices ⚫ 30 Reconstructive Surgery ⚫ 30 Self-Help Programs  31 Sleep Apnea Treatment ⚫ 31 Social Adjustment  31 Speech Therapy ⚫ 31 Surgery ⚫ 31 Telehealth Services ⚫  31

Temporomandibular Joint Disorder ⚫  31 (TMD) Transplants ⚫  31 Travel or Lodging Costs  3 2

Form Number: Wellmark IA Grp/AGC_ 0121 13 CHRXST At A Glance – Covered and Not Covered

Category Benefits Maximums

Covered NotCovered Page See

Vision Services ⚫ 32 One routine vision examination per benefit year. Wigs or Hairpieces  32 X-ray and Laboratory Services ⚫ 32

Prescription Drugs Please note: To determine if a drug is covered, you must consult the Wellmark Blue Rx Complete Drug List. You are covered for drugs listed on the Wellmark Blue Rx Complete Drug List. If a drug is not on the Wellmark Blue Rx Complete Drug List, it is not covered. For details on drug coverage, drug limitations, and drug exclusions, see the next section, Details – Covered and Not Covered.

CHRXST 14 Form Number: Wellmark IA Grp/AGC_ 0121

3. Details - Covered and Not Covered

All covered services or supplies listed in this section are subject to the general contract provisions and limitations described in this coverage manual. Also see the section General Conditions of Coverage, Exclusions, and Limitations, page 37. If a service or supply is not specifically listed, do not assume it is covered.

Medical

⎯ The air or ground ambulance has the Acupuncture Treatment necessary patient care equipment Not Covered: Acupuncture and and supplies to meet your needs. acupressure treatment. ⎯ Your medical condition requires immediate and rapid ambulance Allergy Testing and transport. Treatment ⎯ In addition to the preceding Covered. requirements, for air ambulance services to be covered, all of the Ambulance Services following must be met: ◼ Your medical condition requires Covered: immediate and rapid air ◼ Professional emergency air and ground ambulance transport that cannot ambulance transportation to a hospital be provided by a ground in the surrounding area where your ambulance; or the point of pick ambulance transportation originates. up is inaccessible by a land All of the following are required to vehicle. qualify for benefits: ◼ Great distances, limited time frames, or other obstacles are ⎯ The services required to treat your illness or injury are not available in involved in getting you to the the facility where you are currently nearest hospital with appropriate receiving care if you are an inpatient facilities for treatment. at a facility. ◼ Your condition is such that the time needed to transport you by ⎯ You are transported to the nearest hospital in the Wellmark Blue POS land poses a threat to your network with adequate facilities to health. treat your medical condition. In an In an emergency situation, if you cannot emergency situation, you should reasonably utilize a Wellmark Blue POS seek care at the nearest appropriate ambulance service, covered services will be facility, whether the facility is in- reimbursed as though they were received network or out-of-network. from a Wellmark Blue POS ambulance service. However, because we do not have ⎯ During transport, your medical condition requires the services that contracts with Out-of-Network Providers are provided only by an air or and they may not accept our payment ground ambulance that is arrangements, you are responsible for any professionally staffed and specially difference between the amount charged and equipped for taking sick or injured our amount paid for a covered service. people to or from a health care ◼ Professional non-emergency ground facility in an emergency. ambulance transportation to a hospital

Form Number: Wellmark IA Grp/DE_ 0121 15 CHRXST Details – Covered and Not Covered

or nursing facility in the surrounding or wheelchairs but are not professionally area where your ambulance operated or staffed. transportation originates. All of the following are required to Anesthesia qualify for benefits: Covered: Anesthesia and the administration of anesthesia. ⎯ The services required to treat your illness or injury are not available in Not Covered: Local or topical anesthesia the facility where you are currently billed separately from related surgical or receiving care. medical procedures. ⎯ You are transported to the nearest hospital or nursing facility with Autism Spectrum Disorder adequate facilities to treat your Treatment medical condition. Covered: Diagnosis and treatment of ⎯ During transport your medical autism spectrum disorder and Applied condition requires the services that Behavior Analysis services for the treatment are provided only by a ground of autism spectrum disorder for children ambulance that is professionally age 18 and younger when Applied Behavior staffed and specially equipped for Analysis services are performed or taking sick or injured people to or supervised pursuant to an approved from a health care facility. treatment plan by a licensed physician or ⎯ The ground ambulance has the psychologist or a master’s or doctoral degree necessary patient care equipment holder certified by the National Behavior and supplies to meet your needs. Analyst Certification Board with a Not Covered: designation of board certified behavior analyst. Autism spectrum disorder is a ◼ Professional air or ground ambulance complex neurodevelopmental medical transport from a facility capable of disorder characterized by social treating your condition. impairment, communication difficulties, ◼ Professional ground ambulance and restricted, repetitive, and stereotyped transport to or from any location when patterns of behavior. you are physically and mentally capable of being a passenger in a private vehicle. Benefits Maximum: ◼ Professional ground ambulance round- ◼ Applied Behavior Analysis services for trip transports from your residence to a the treatment of autism spectrum medical provider for an appointment or disorder for children age 18 and treatment and back to your residence. younger: ◼ Professional air or ground transport ⎯ For children through age six: when performed primarily for your $36,000 per calendar year. convenience or the convenience of your ⎯ For children age seven through age family, physician, or other health care 13: $25,000 per calendar year. provider. ⎯ For children age 14 through age 18: ◼ Professional, non-emergency air $12,500 per calendar year. ambulance transports to any location for Not Covered: any reason. ◼ ◼ Nonprofessional air or ground Applied Behavior Analysis services for ambulance transports to any location for the treatment of autism spectrum any reason. This includes non- disorder for members age 19 and older. ambulance vehicles such as vans or taxis that are equipped to transport stretchers

CHRXST 16 Form Number: Wellmark IA Grp/DE_ 0121 Details – Covered and Not Covered

◼ Applied Behavior Analysis services other general hospital or a medically managed than for the treatment of autism inpatient treatment program. spectrum disorder. Not Covered: Blood and Blood ◼ Room and board provided while participating in a clinically managed low Administration intensity residential treatment setting, Covered: Whole blood, blood components, also known as supervised living. blood derivatives, and blood administration. ◼ Recreational activities or therapy, social Please note: Whole blood and blood activities, meals, excursions or other components are typically made available to activities not considered clinical you at no charge through the facility from treatment, while participating in which you receive services. substance abuse treatment programs. See Also: Chemical Dependency Hospitals and Facilities later in this section. Treatment Notification Requirements and Care Covered: Treatment for a condition with Coordination, page 53. physical or psychological symptoms produced by the habitual use of certain drugs or alcohol as described in the most Chemotherapy and Radiation current Diagnostic and Statistical Manual Therapy of Mental Disorders. Covered: Use of chemical agents or radiation to treat or control a serious illness. Licensed Substance Abuse Treatment Program. Benefits are available for Clinical Trials – Routine Care chemical dependency treatment in the following settings: Associated with Clinical Trials ◼ Treatment provided in an office visit, or outpatient setting; Covered: Medically necessary routine patient costs for items and services ◼ Treatment provided in an intensive otherwise covered under this plan furnished outpatient setting; in connection with participation in an ◼ Treatment provided in an outpatient approved clinical trial related to the partial hospitalization setting; treatment of cancer or other life-threatening ◼ Drug or alcohol rehabilitation therapy or diseases or conditions, when a covered counseling provided while participating member is referred by a Wellmark Blue POS in a clinically managed low intensity Provider based on the conclusion that the residential treatment setting, also member is eligible to participate in an known as supervised living; approved clinical trial according to the trial ◼ Treatment, including room and board, protocol or the member provides medical provided in a clinically managed and scientific information establishing that medium or high intensity residential the member’s participation in the clinical treatment setting; trial would be appropriate according to the ◼ Treatment provided in a medically trial protocol. monitored intensive inpatient or Not Covered: detoxification setting; and ◼ Investigational or experimental items, ◼ For inpatient, medically managed acute care for patients whose condition devices, or services which are requires the resources of an acute care themselves the subject of the clinical trial;

Form Number: Wellmark IA Grp/DE_ 0121 17 CHRXST Details – Covered and Not Covered

◼ Clinical trials, items, and services that Counseling and Education are provided solely to satisfy data Services collection and analysis needs and that are not used in the direct clinical Covered: management of the patient; ◼ Family or marriage counseling or ◼ Services that are clearly inconsistent services. with widely accepted and established Not Covered: standards of care for a particular ◼ Bereavement counseling or services. diagnosis. ◼ Community-based services or services of Contraceptives volunteers or clergy. Covered: The following conception ◼ Education or educational therapy other prevention, as approved by the U.S. Food than covered lactation consultant and Drug Administration: services, education for self-management of diabetes, or nutrition education. ◼ Contraceptive medical devices, such as ◼ Learning and educational services and intrauterine devices and diaphragms. treatments including, but not limited to, ◼ Implanted contraceptives. non-drug therapy for high blood ◼ Injected contraceptives. pressure control, exercise modalities for Please note: Contraceptive drugs and weight reduction, nutritional instruction contraceptive drug delivery devices, such as for the control of gastrointestinal insertable rings and patches are covered conditions, or reading programs for under your Blue Rx Complete prescription dyslexia for any medical, mental health, drug benefits described later in this section. or substance abuse condition. ◼ Weight reduction programs or supplies See the Wellmark Blue Rx Complete Drug (including dietary supplements, foods, List at Wellmark.com or call the Customer equipment, lab testing, examinations, Service number on your ID card and request and prescription drugs), whether or not a copy of the Drug List. weight reduction is medically Conversion Therapy appropriate. See Also: Not Covered: Conversion therapy services. Genetic Testing later in this section. Cosmetic Services Education Services for Diabetes and Not Covered: Cosmetic services, supplies, Nutrition later in this section. or drugs if provided primarily to improve Mental Health Services later in this section. physical appearance. However, a service, supply, or drug that results in an incidental Preventive Care later in this section. improvement in appearance may be covered if it is provided primarily to restore function Dental Services lost or impaired as the result of an illness, Covered: accidental injury, or a birth defect. You are also not covered for treatment for any ◼ Dental treatment for accidental injuries complications resulting from a noncovered when all of the following requirements cosmetic procedure. are met: ⎯ Initial treatment is received within See Also: 12 months of the injury. Reconstructive Surgery later in this section. ⎯ Follow-up treatment is completed within 24 months.

CHRXST 18 Form Number: Wellmark IA Grp/DE_ 0121 Details – Covered and Not Covered

◼ Anesthesia (general) and hospital or Not Covered: ambulatory surgical facility services ◼ General dentistry including, but not related to covered dental services if: limited to, diagnostic and preventive ⎯ You are under age 14 and, based on a services, restorative services, endodontic determination by a licensed dentist services, periodontal services, indirect and your treating physician, you fabrications, dentures and bridges, and have a dental or developmental orthodontic services unrelated to condition for which patient accidental injuries or management of management in the dental office has cleft palate. been ineffective and requires dental ◼ Injuries associated with or resulting treatment in a hospital or from the act of chewing. ambulatory surgical facility; or ◼ Maxillary or mandibular tooth implants ⎯ Based on a determination by a (osseointegration) unrelated to licensed dentist and your treating accidental injuries or abnormal changes physician, you have one or more in the mouth due to injury or disease. medical conditions that would create significant or undue medical risk in Dialysis the course of delivery of any necessary dental treatment or Covered: Removal of toxic substances surgery if not rendered in a hospital from the blood when the kidneys are unable or ambulatory surgical facility. to do so when provided as an inpatient in a hospital setting or as an outpatient in a ◼ Impacted teeth removal (surgical) only Medicare-approved dialysis center. when you have a medical condition (such as hemophilia) that requires hospitalization. Education Services for ◼ Facial bone fracture reduction. Diabetes and Nutrition ◼ Incisions of accessory sinus, mouth, Covered: Inpatient and outpatient training salivary glands, or ducts. and education for the self-management of all types of diabetes mellitus. ◼ Jaw dislocation manipulation. ◼ Orthodontic services associated with All covered training or education must be management of cleft palate. prescribed by a licensed physician. ◼ Treatment of abnormal changes in the Outpatient training or education must be mouth due to injury or disease of the provided by a state-certified program. mouth, or dental care (oral examination, The state-certified diabetic education x-rays, extractions, and nonsurgical program helps any type of diabetic and his elimination of oral infection) required or her family understand the diabetes for the direct treatment of a medical disease process and the daily management condition, limited to: of diabetes. ⎯ Dental services related to medical You are also covered for nutrition education transplant procedures; to improve your understanding of your ⎯ Initiation of immunosuppressives metabolic nutritional condition and provide (medication used to reduce you with information to manage your inflammation and suppress the nutritional requirements. Nutrition immune system); or education is appropriate for the following ⎯ Treatment of neoplasms of the conditions: mouth and contiguous tissue. ◼ Cancer. ◼ Cystic fibrosis. ◼ Diabetes.

Form Number: Wellmark IA Grp/DE_ 0121 19 CHRXST Details – Covered and Not Covered

◼ Eating disorders. ◼ Fertility and infertility services until you ◼ Glucose intolerance. receive artificial insemination, in vitro ◼ High blood pressure. fertilization, or any related fertility or infertility treatment or transfer ◼ High cholesterol. procedure. ◼ Lactose intolerance. Not Covered: ◼ Malabsorption, including gluten intolerance. ◼ Infertility treatment if the infertility is ◼ Morbid obesity. the result of voluntary sterilization. ◼ Underweight. ◼ The collection or purchase of donor semen (sperm) or oocytes (eggs) when Emergency Services performed in connection with fertility or infertility procedures or for any other Covered: When treatment is for a medical reason or service; freezing and storage condition manifested by acute symptoms of of sperm, oocytes, or embryos; surrogate sufficient severity, including pain, that a parent services. prudent layperson, with an average knowledge of health and medicine, could ◼ Artificial insemination, in vitro reasonably expect absence of immediate fertilization, or any related fertility or infertility treatment or transfer medical attention to result in: procedure. If you have any of these ◼ Placing the health of the individual or, procedures done, benefits for all types of with respect to a pregnant woman, the fertility or infertility treatment health of the woman and her unborn (including drug induced stimulation of child, in serious jeopardy; or ovulation) will end beginning on the day ◼ Serious impairment to bodily function; you receive the noncovered service. or ◼ Reversal of a tubal ligation (or its ◼ Serious dysfunction of any bodily organ equivalent) or vasectomy. or part. In an emergency situation, if you cannot Genetic Testing reasonably reach a Wellmark Blue POS Covered: Genetic molecular testing Provider, covered services will be (specific gene identification) and related reimbursed as though they were received counseling are covered when both of the from a Wellmark Blue POS Provider. following requirements are met: However, because we do not have contracts ◼ You are an appropriate candidate for a with Out-of-Network Providers and they test under medically recognized may not accept our payment arrangements, standards (for example, family you are responsible for any difference background, past diagnosis, etc.). between the amount charged and our amount paid for a covered service. ◼ The outcome of the test is expected to determine a covered course of treatment See Also: or prevention and is not merely Out-of-Network Providers, page 61. informational.

Fertility and Infertility Hearing Services Services Covered: Covered: ◼ Hearing examinations, but only to test or treat hearing loss related to an illness ◼ Fertility prevention, such as tubal ligation (or its equivalent) or vasectomy or injury. (initial surgery only).

CHRXST 20 Form Number: Wellmark IA Grp/DE_ 0121 Details – Covered and Not Covered

Not Covered: ⎯ provides teaching to caregivers for ongoing care; or ◼ Hearing aids. ⎯ provides short-term treatments that ◼ Routine hearing examinations. can be safely administered in the Home Health Services home setting. The daily benefit for short-term home Covered: All of the following requirements skilled nursing services will not exceed must be met in order for home health Wellmark’s daily maximum allowable services to be covered: fee for care in a skilled nursing facility. ◼ You require a medically necessary Benefits do not include maintenance or skilled service such as skilled nursing, custodial care or services provided for physical therapy, or speech therapy. the convenience of the family caregiver. ◼ Services are received from an agency Inhalation Therapy. accredited by the Joint Commission for Accreditation of Health Care Medical Equipment. Organizations (JCAHO) and/or a Medical Social Services. Medicare-certified agency. Medical Supplies. ◼ Services are prescribed by a physician and approved by Wellmark for the Occupational Therapy—but only for treatment of illness or injury. services to treat the upper extremities, ◼ Services are not more costly than which means the arms from the alternative services that would be shoulders to the fingers. You are not effective for diagnosis and treatment of covered for occupational therapy your condition. supplies. ◼ The care is referred by your designated Oxygen and Equipment for its personal doctor or a Wellmark Blue POS administration. Provider and approved by Wellmark. Parenteral and Enteral Nutrition, The following are covered services and except enteral formula administered supplies: orally. Home Health Aide Services—when Physical Therapy. provided in conjunction with a medically necessary skilled service also Prescription Drugs and Medicines received in the home. administered in the vein or muscle. Short-Term Home Skilled Prosthetic Devices and Braces. Nursing. Treatment must be given by a Speech Therapy. registered nurse (R.N.) or licensed practical nurse (L.P.N.) from an agency Not Covered: accredited by the Joint Commission for ◼ Custodial home care services and Accreditation of Health Care supplies, which help you with your daily Organizations (JCAHO) or a Medicare- living activities. This type of care does certified agency. Short-term home not require the continuing attention and skilled nursing means home skilled assistance of licensed medical or trained nursing care that: paramedical personnel. Some examples

⎯ is provided for a definite limited of custodial care are assistance in period of time as a safe transition walking and getting in and out of bed; from other levels of care when aid in bathing, dressing, feeding, and medically necessary; other forms of assistance with normal bodily functions; preparation of special

Form Number: Wellmark IA Grp/DE_ 0121 21 CHRXST Details – Covered and Not Covered

diets; and supervision of medication same services as described under Home that can usually be self-administered. Health Services, as well as hospice respite You are also not covered for sanitaria care from a facility approved by Medicare or care or rest cures. by the Joint Commission for Accreditation ◼ Extended home skilled nursing. of Health Care Organizations (JCAHO). See Also: Hospice respite care offers rest and relief Referrals, page 45. help for the family caring for a terminally ill patient. Inpatient respite care can take place Home/Durable Medical in a nursing home, nursing facility, or Equipment hospital. Covered: Equipment that meets all of the Benefits Maximum: following requirements: ◼ 15 days per lifetime for inpatient ◼ The equipment is ordered by a provider hospice respite care. within the scope of his or her license and ◼ 15 days per lifetime for outpatient there is a written prescription. hospice respite care. ◼ Durable enough to withstand repeated ◼ Not more than five days of hospice use. respite care at a time. ◼ Primarily and customarily manufactured to serve a medical Hospitals and Facilities purpose. Covered: Hospitals and other facilities that ◼ Used to serve a medical purpose. meet standards of licensing, accreditation or ◼ Standard or basic home/durable certification. Following are some recognized medical equipment that will adequately facilities: meet the medical needs and that does Ambulatory Surgical Facility. This not have certain deluxe/luxury or type of facility provides surgical services convenience upgrade or add-on features. on an outpatient basis for patients who In addition, we determine whether to pay do not need to occupy an inpatient the rental amount or the purchase price hospital bed and must be licensed as an amount for an item, and we determine the ambulatory surgical facility under length of any rental term. Benefits will never applicable law. exceed the lesser of the amount charged or Chemical Dependency Treatment the maximum allowable fee. Facility. This type of facility must be See Also: licensed as a chemical dependency treatment facility under applicable law. Medical and Surgical Supplies and Personal Convenience Items later in this Community Mental Health Center. section. This type of facility provides treatment of mental health conditions and must be Orthotics (Foot) later in this section. licensed as a community mental health Prosthetic Devices later in this section. center under applicable law. Referrals, page 45. Hospital. This type of facility provides for the diagnosis, treatment, or care of Hospice Services injured or sick persons on an inpatient Covered: Care (generally in a home and outpatient basis. The facility must setting) for patients who are terminally ill be licensed as a hospital under and who have a life expectancy of six applicable law. months or less. Hospice care covers the

CHRXST 22 Form Number: Wellmark IA Grp/DE_ 0121 Details – Covered and Not Covered

Nursing Facility. This type of facility Illness or Injury Services provides continuous skilled nursing Covered: services as ordered and certified by your attending physician on an inpatient ◼ Services or supplies used to treat any basis for short-term care. Benefits do bodily disorder, bodily injury, disease, not include maintenance or custodial or mental health condition unless care or services provided for the specifically addressed elsewhere in this convenience of the family caregiver. The section. This includes pregnancy and facility must be licensed as a nursing complications of pregnancy. facility under applicable law. ◼ Routine foot care related to the Psychiatric Medical Institution for treatment of a metabolic, neurological, Children (PMIC). This type of facility or peripheral vascular disease. provides inpatient psychiatric services to Treatment may be received from an children and is licensed as a PMIC under approved provider in any of the following Iowa Code Chapter 135H. settings: Precertification is required. For ◼ Home. information on how to precertify, refer ◼ Inpatient (such as a hospital or nursing to Precertification in the Notification facility). Requirements and Care Coordination ◼ Office (such as a doctor’s office). section of this coverage manual, or call ◼ Outpatient. the Customer Service number on your Not Covered: ID card. ◼ Long term acute care services typically Urgent Care Center. This type of provided by a long term acute care facility provides medical care without an facility. appointment during all hours of ◼ Room and board provided while a operation to walk-in patients of all ages patient at an intermediate care facility who are ill or injured and require or similar level of care. immediate care but may not require the services of a hospital emergency room. ◼ Routine foot care, including related services or supplies, except as described Benefits Maximum: under Covered. ◼ 90 days per benefit year for skilled nursing services in a hospital or nursing Inhalation Therapy facility. Covered: Respiratory or breathing Not Covered: treatments to help restore or improve breathing function. ◼ Long Term Acute Care Facility. ◼ Room and board provided while a Maternity Services patient at an intermediate care facility Covered: Prenatal and postnatal care, or similar level of care. delivery, including complications of See Also: pregnancy. A complication of pregnancy Chemical Dependency Treatment earlier in refers to a cesarean section that was not this section. planned, an ectopic pregnancy that is terminated, or a spontaneous termination of Mental Health Services later in this section. pregnancy that occurs during a period of gestation in which a viable birth is not possible. Complications of pregnancy also include conditions requiring inpatient hospital admission (when pregnancy is not

Form Number: Wellmark IA Grp/DE_ 0121 23 CHRXST Details – Covered and Not Covered terminated) whose diagnoses are distinct Medical and Surgical from pregnancy but are adversely affected Supplies and Personal by pregnancy or are caused by pregnancy. Convenience Items Please note: You must notify us or your Covered: Medical supplies and devices employer or group sponsor if you enter into such as: an arrangement to provide surrogate parent services: Contact your employer or group ◼ Dressings and casts. sponsor or call the Customer Service ◼ Oxygen and equipment needed to number on your ID card. administer the oxygen. In accordance with federal or applicable ◼ Diabetic equipment and state law, maternity services include a supplies purchased from a covered minimum of: provider. Not Covered: Unless otherwise required ◼ 48 hours of inpatient care (in addition to by law, supplies, equipment, or drugs the day of delivery care) following a available for general retail purchase or items vaginal delivery, or used for your personal convenience ◼ 96 hours of inpatient care (in addition to including, but not limited to: the day of delivery) following a cesarean section. ◼ Band-aids, gauze, bandages, tape, non- sterile gloves, thermometers, heating A practitioner is not required to seek pads, cooling devices, cold packs, Wellmark’s review in order to prescribe a heating devices, hot water bottles, home length of stay of less than 48 or 96 hours. enema equipment, sterile water, bed The attending practitioner, in consultation boards, alcohol wipes, or incontinence with the mother, may discharge the mother products; or newborn prior to 48 or 96 hours, as applicable. ◼ Elastic stockings or bandages including trusses, lumbar braces, garter belts, and Coverage includes one follow-up similar items that can be purchased postpartum home visit by a registered nurse without a prescription; (R.N.). This nurse must be from a home ◼ Escalators, elevators, ramps, stair glides, health agency under contract with Wellmark emergency/alert equipment, handrails, or employed by the delivering physician. heat appliances, improvements made to If you have a newborn child, but you do not a member's house or place of business, add that child to your coverage, your or adjustments made to vehicles; newborn child may be added to your ◼ Household supplies including, but not coverage solely for the purpose of limited to: deluxe/luxury equipment or administering benefits for the newborn non-essential features, such as motor- during the first 48 hours following a vaginal driven chairs or bed, electric stair chairs delivery or 96 hours following a cesarean or elevator chairs, or sitz bath; delivery. If that occurs, a separate ◼ Items not primarily and customarily deductible and coinsurance may be applied manufactured to serve a medical to your newborn child unless your coverage purpose or which can be used in the specifically waives the deductible or absence of illness or injury including, coinsurance for your newborn child. but not limited to, air conditioners, hot See Also: tubs, or swimming pools; ◼ Items that do not serve a medical Coverage Change Events, page 71. purpose or are not needed to serve a medical purpose;

CHRXST 24 Form Number: Wellmark IA Grp/DE_ 0121 Details – Covered and Not Covered

◼ Rental or purchase of equipment if you ◼ Treatment provided in an office visit, or are in a facility which provides such outpatient setting; equipment; ◼ Treatment provided in an intensive ◼ Rental or purchase of exercise cycles, outpatient setting; physical fitness, exercise and massage ◼ Treatment provided in an outpatient equipment, ultraviolet/tanning partial hospitalization setting; equipment, or traction devices; and ◼ Individual, group, or family therapy ◼ Water purifiers, hypo-allergenic pillows, provided in a clinically managed low mattresses or waterbeds, whirlpool, spa, intensity residential treatment setting, air purifiers, humidifiers, or also known as supervised living; dehumidifiers. ◼ Treatment, including room and board, See Also: provided in a clinically managed Home/Durable Medical Equipment earlier medium or high intensity residential in this section. treatment setting; ◼ Psychiatric observation; Orthotics (Foot) later in this section. ◼ Care provided in a psychiatric Prescription Drugs, page 32. residential crisis program; Prosthetic Devices later in this section. ◼ Care provided in a medically monitored intensive inpatient setting; and Mental Health Services ◼ For inpatient, medically managed acute Covered: Treatment for certain care for patients whose condition psychiatric, psychological, or emotional requires the resources of an acute care conditions as an inpatient or outpatient. general hospital or a medically managed Covered facilities for mental health services inpatient treatment program. include licensed and accredited residential Not Covered: Treatment for: treatment facilities and community mental ◼ Certain disorders related to early health centers. childhood, such as academic To qualify for mental health treatment underachievement disorder. benefits, the following requirements must ◼ Communication disorders, such as be met: stuttering and stammering.

◼ The disorder is classified as a mental ◼ Impulse control disorders. health condition in the Diagnostic and ◼ Conditions that are not pervasive Statistical Manual of Mental Disorders, developmental and learning disorders. Fifth Edition (DSM-V) or subsequent ◼ Sensitivity, shyness, and social revisions, except as otherwise provided withdrawal disorders. in this coverage manual. ◼ Sexual disorders. ◼ The disorder is listed only as a mental ◼ Room and board provided while health condition and not dually listed participating in a clinically managed low elsewhere in the most current version of intensity residential treatment setting, International Classification of Diseases, also known as supervised living. Clinical Modification used for diagnosis ◼ Recreational activities or therapy, social coding. activities, meals, excursions or other Licensed Psychiatric or Mental Health activities not considered clinical Treatment Program Services. Benefits treatment, while participating in are available for mental health treatment in residential psychiatric treatment the following settings: programs.

Form Number: Wellmark IA Grp/DE_ 0121 25 CHRXST Details – Covered and Not Covered

See Also: through a feeding tube, except for permanent inborn errors of metabolism. Chemical Dependency Treatment and Hospitals and Facilities earlier in this Not Covered: Other prescription and non- section. prescription nutritional and dietary supplements including, but not limited to:

Motor Vehicles ◼ Food products. Not Covered: Purchase or rental of motor ◼ Grocery items or food products that are vehicles such as cars or vans. You are also modified for special diets for individuals not covered for equipment or costs with inborn errors of metabolism but associated with converting a motor vehicle which can be purchased without a to accommodate a disability. prescription issued by or authorized by a licensed healthcare practitioner, Musculoskeletal Treatment including low protein/low phe grocery Covered: Outpatient nonsurgical items. treatment of ailments related to the ◼ Herbal products. musculoskeletal system, such as ◼ Fish oil products. manipulations or related procedures to treat ◼ Medical foods, except as described musculoskeletal injury or disease. under Covered. Not Covered: Massage therapy. ◼ Minerals. ◼ Supplementary vitamin preparations. Nonmedical or ◼ Multivitamins. Administrative Services Not Covered: Such services as telephone Occupational Therapy consultations, charges for failure to keep Covered: Occupational therapy services scheduled appointments, charges for are covered when all the following completion of any form, charges for medical requirements are met: information, recreational therapy and other ◼ Services are to treat the upper sensory-type activities, administrative extremities, which means the arms from services (such as interpretive services, pre- the shoulders to the fingers. care assessments, health risk assessments, case management, care coordination, or ◼ The goal of the occupational therapy is development of treatment plans) when improvement of an impairment or billed separately, and any services or functional limitation. supplies that are nonmedical. ◼ The potential for rehabilitation is significant in relation to the extent and Nutritional and Dietary duration of services. Supplements ◼ The expectation for improvement is in a reasonable (and generally predictable) Covered: period of time. ◼ Nutritional and dietary supplements ◼ There is evidence of improvement by that cannot be dispensed without a successive objective measurements prescription issued by or authorized by a whenever possible. licensed health care practitioner and are Not Covered: prescribed by a licensed health care practitioner for permanent inborn ◼ Occupational therapy supplies. errors of metabolism, such as PKU. ◼ Occupational therapy provided as an ◼ Enteral and nutritional therapy only inpatient in the absence of a separate when prescribed feeding is administered medical condition that requires hospitalization.

CHRXST 26 Form Number: Wellmark IA Grp/DE_ 0121 Details – Covered and Not Covered

◼ Occupational therapy performed for Physicians and Practitioners maintenance. Covered: Most services provided by ◼ Occupational therapy services that do practitioners that are recognized by us and not meet the requirements specified meet standards of licensing, accreditation or under Covered. certification. Following are some recognized physicians and practitioners: Orthotics (Foot) Advanced Registered Nurse Covered: Orthotics training. Practitioners (ARNP). An ARNP is a Not Covered: Orthotic foot devices such as registered nurse with advanced training arch supports or in-shoe supports, in a specialty area who is registered with orthopedic shoes, elastic supports, or the Iowa Board of Nursing to practice in examinations to prescribe or fit such an advanced role with a specialty devices. designation of certified clinical nurse See Also: specialist, certified nurse midwife, certified nurse practitioner, or certified Home/Durable Medical Equipment earlier registered nurse anesthetist. in this section. Audiologists. Prosthetic Devices later in this section. Chiropractors. Physical Therapy Doctors of Osteopathy (D.O.). Covered: Physical therapy services are Licensed Independent Social covered when all the following requirements Workers. are met: Medical Doctors (M.D.). ◼ The goal of the physical therapy is improvement of an impairment or Occupational Therapists. This functional limitation. provider is covered only when treating the upper extremities, which means the ◼ The potential for rehabilitation or habilitation is significant in relation to arms from the shoulders to the fingers. the extent and duration of services. Optometrists. ◼ The expectation for improvement is in a Oral Surgeons. reasonable (and generally predictable) period of time. Physical Therapists. ◼ There is evidence of improvement by Physician Assistants. successive objective measurements Podiatrists. whenever possible. Not Covered: Psychologists. Psychologists must have a doctorate degree in psychology ◼ Physical therapy provided as an with two years’ clinical experience and inpatient in the absence of a separate meet the standards of a national medical condition that requires register. hospitalization. ◼ Physical therapy performed for Speech Pathologists. maintenance. See Also: ◼ Physical therapy services that do not Choosing a Provider, page 43. meet the requirements specified under Covered.

Form Number: Wellmark IA Grp/DE_ 0121 27 CHRXST Details – Covered and Not Covered

Prescription Drugs inhaled drugs typically used for treating or managing chronic illnesses. These Covered: Most prescription drugs and drugs often require special handling medicines that bear the legend, “Caution, (e.g., refrigeration) and administration. Federal Law prohibits dispensing without a They are not available through the mail prescription,” are generally covered under order drug program. your Blue Rx Complete prescription drug benefits, not under your medical benefits. Specialty drugs may be covered under However, there are exceptions when your medical benefits or under your prescription drugs and medicines are Blue Rx Complete prescription drug covered under your medical benefits. benefits. If a specialty drug that is covered under your medical benefits is Drugs classified by the FDA as Drug Efficacy not provided by your physician, you Study Implementation (DESI) drugs may must purchase specialty drugs through also be covered. For a list of these drugs, the specialty pharmacy program. To visit our website at Wellmark.com or check determine whether a particular specialty with your pharmacist or physician. drug is covered under your medical Drugs listed on the Drug List are established benefits or under your Blue Rx Complete and maintained by Wellmark’s Pharmacy & prescription drug benefits, consult the Therapeutics (P&T) Committee. The P&T Wellmark Blue Rx Complete Drug List Committee is a group of independent at Wellmark.com, or call the Customer practicing healthcare providers such as Service number on your ID card. See physicians and pharmacists who regularly Specialty Pharmacy Program, page 51. meet to review the safety, effectiveness, and You are not covered for specialty drugs value of new and existing medications and purchased outside the specialty make any necessary changes to the coverage pharmacy program unless the specialty of medications. Drugs will not be covered drug is covered under your medical until they have been evaluated and benefits. approved to be covered by Wellmark’s P&T Committee. Drugs previously approved by Take-Home Drugs. Take-home drugs Wellmark’s P&T Committee will no longer are drugs dispensed and billed by a be covered if Wellmark’s P&T Committee hospital or other facility for a short-term discontinues approval of the drugs. supply. Prescription drugs and medicines that may Not Covered: Some prescription drugs, be covered under your medical benefits services, and items are not covered under include: either your medical benefits or your Blue Rx Complete benefits. For example: Drugs and Biologicals. Drugs and biologicals approved by the U.S. Food ◼ Antigen therapy. and Drug Administration. This includes ◼ Medication Therapy Management such supplies as serum, vaccine, (MTM) when billed separately. antitoxin, or antigen used in the ◼ Drugs purchased outside the United prevention or treatment of disease. States failing the requirements specified Intravenous Administration. earlier in this section. Intravenous administration of nutrients, ◼ Difference in cost between the generic antibiotics, and other drugs and fluids drug and the brand name drug when when provided in the home (home you purchase a brand name drug that infusion therapy). has an FDA-approved "A"-rated medically appropriate generic Specialty Drugs. Specialty drugs are equivalent. high-cost injectable, infused, oral, or

CHRXST 28 Form Number: Wellmark IA Grp/DE_ 0121 Details – Covered and Not Covered

◼ Prescription drugs or pharmacy durable ◼ Preventive items and services including, medical equipment devices that are not but not limited to: FDA-approved. ⎯ Items or services with an “A” or “B” ◼ Prescription drugs that are not approved rating in the current to be covered by Wellmark’s P&T recommendations of the United Committee. States Preventive Services Task Some prescription drugs are covered under Force (USPSTF); your Blue Rx Complete benefits: ⎯ Immunizations as recommended by the Advisory Committee on ◼ Insulin. Immunization Practices of the See the Wellmark Blue Rx Complete Drug Centers for Disease Control and List at Wellmark.com or call the Customer Prevention (ACIP); Service number on your ID card and request ⎯ Preventive care and screenings for a copy of the Drug List. infants, children and adolescents See Also: provided for in the guidelines Contraceptives earlier in this section. supported by the Health Resources and Services Administration Medical and Surgical Supplies and (HRSA); and Personal Convenience Items earlier in this ⎯ Preventive care and screenings for section. women provided for in guidelines Notification Requirements and Care supported by the HRSA. Coordination, page 53. ◼ Well-child care including age- Prescription Drugs later in this section. appropriate pediatric preventive services, as defined by current Prior Authorization, page 57. recommendations for Preventive Pediatric Health Care of the American Preventive Care Academy of Pediatrics. Pediatric Covered: Preventive care such as: preventive services shall include, at minimum, a history and complete ◼ Breastfeeding support, supplies, and physical examination as well as one-on-one lactation consultant developmental assessment, anticipatory services, including counseling and guidance, immunizations, and education, provided during pregnancy laboratory services including, but not and/or the duration of breastfeeding limited to, screening for lead exposure received from a provider acting within as well as blood levels. the scope of their licensure or certification under state law. It is usually to your advantage to receive preventive care from your designated ◼ Digital breast tomosynthesis (3D personal doctor or from your designated mammogram). OB/GYN care provider. The following ◼ Gynecological examinations. preventive services must be provided by ◼ Mammograms. your designated personal doctor to be ◼ Medical evaluations and counseling for covered: nicotine dependence per U.S. Preventive ◼ Preventive Physical Examination. Services Task Force (USPSTF) guidelines. ◼ Preventive Gynecological Examination. You may receive your ◼ Pap smears. preventive gynecological examination ◼ Physical examinations. from your designated personal doctor or your selected OB/GYN.

Form Number: Wellmark IA Grp/DE_ 0121 29 CHRXST Details – Covered and Not Covered

◼ Well-Child Examination. support a weak or deformed body part or to Benefits Maximum: restrict or eliminate motion in a diseased or injured part of the body. Braces do not ◼ Well-child care until the child reaches include elastic stockings, elastic bandages, age seven. garter belts, arch supports, orthodontic ◼ One routine physical examination per devices, or other similar items. benefit year. Not Covered: ◼ One routine mammogram per benefit year. ◼ Devices such as air conduction hearing ◼ One routine gynecological examination aids or examinations for their per benefit year. prescription or fitting. ◼ One routine Pap smear per benefit year. ◼ Elastic stockings or bandages including Please note: Physical examination limits trusses, lumbar braces, garter belts, and do not include items or services with an “A” similar items that can be purchased or “B” rating in the current without a prescription. recommendations of the USPSTF, See Also: immunizations as recommended by ACIP, Home/Durable Medical Equipment earlier and preventive care and screening in this section. guidelines supported by the HRSA, as described under Covered. Medical and Surgical Supplies and Personal Convenience Items earlier in this Not Covered: section. ◼ Periodic physicals or health Orthotics (Foot) earlier in this section. examinations, screening procedures, or immunizations performed solely for Referrals, page 45. school, sports, employment, insurance, licensing, or travel, or other Reconstructive Surgery administrative purposes. Covered: Reconstructive surgery primarily ◼ Group lactation consultant services. intended to restore function lost or ◼ All treatment related to nicotine impaired as the result of an illness, injury, dependence, except as described under or a birth defect (even if there is an Covered. For prescription drugs and incidental improvement in physical devices used to treat nicotine appearance) including breast reconstructive dependence, including over-the-counter surgery following mastectomy. Breast drugs prescribed by a physician, please reconstructive surgery includes the see your Blue Rx Complete prescription following: drug benefits. ◼ Reconstruction of the breast on which See Also: the mastectomy has been performed. Hearing Services earlier in this section. ◼ Surgery and reconstruction of the other breast to produce a symmetrical Vision Services later in this section. appearance. ◼ Prostheses. Prosthetic Devices ◼ Treatment of physical complications of Covered: Devices used as artificial the mastectomy, including substitutes to replace a missing natural part lymphedemas. of the body or to improve, aid, or increase See Also: the performance of a natural function. Cosmetic Services earlier in this section. Also covered are braces, which are rigid or semi-rigid devices commonly used to

CHRXST 30 Form Number: Wellmark IA Grp/DE_ 0121 Details – Covered and Not Covered

Self-Help Programs Telehealth Services Not Covered: Self-help and self-cure Covered: You are covered for telehealth products or drugs. services delivered to you by a covered practitioner acting within the scope of his or Sleep Apnea Treatment her license or certification or by a Covered: Obstructive sleep apnea practitioner contracting through Doctor on diagnosis and treatments. Demand via real-time, interactive audio- visual technology or web-based mobile Not Covered: Treatment for snoring device or similar electronic-based without a diagnosis of obstructive sleep communication network. Services must be apnea. delivered in accordance with applicable law and generally accepted health care Social Adjustment practices. Not Covered: Services or supplies Please note: Members can access intended to address social adjustment or telehealth services from Doctor on Demand economic needs that are typically not through the Doctor on Demand mobile medical in nature. application. Speech Therapy Not Covered: Medical services provided Covered: Rehabilitative speech therapy through means other than interactive, real- services when related to a specific illness, time audio-visual technology, including, but injury, or impairment, including speech not limited to, audio-only telephone, therapy services for the treatment of autism electronic mail message, or facsimile spectrum disorder, that involve the transmission. mechanics of phonation, articulation, or swallowing. Services must be provided by a Temporomandibular Joint licensed or certified speech pathologist. Disorder (TMD) Not Covered: Covered. Not Covered: Routine dental services, ◼ Speech therapy services not provided by a licensed or certified speech dental extractions, dental restorations, or pathologist. orthodontic treatment for temporomandibular joint disorders. ◼ Speech therapy to treat certain developmental, learning, or communication disorders, such as Transplants stuttering and stammering. Covered: ◼ Certain bone marrow/stem cell transfers Surgery from a living donor. Covered. This includes the following: ◼ Heart.

◼ Major endoscopic procedures. ◼ Heart and lung. ◼ Operative and cutting procedures. ◼ Kidney. ◼ Preoperative and postoperative care. ◼ Liver. See Also: ◼ Lung. ◼ Pancreas. Dental Services earlier in this section. ◼ Simultaneous pancreas/kidney. Reconstructive Surgery earlier in this ◼ Small bowel. section. You are also covered for the medically necessary expenses of transporting the

Form Number: Wellmark IA Grp/DE_ 0121 31 CHRXST Details – Covered and Not Covered

recipient when the transplant organ for the ◼ Eyeglasses, but only when prescribed as recipient is available for transplant. the result of cataract extraction. Transplants are subject to case ◼ Contact lenses, but only when management. prescribed as the result of cataract extraction or when the underlying Charges related to the donation of an organ diagnosis is a corneal injury or corneal are usually covered by the recipient’s disease. medical benefits plan. However, if donor Benefits Maximum: charges are excluded by the recipient’s plan, and you are a donor, the charges will be ◼ One routine vision examination per covered by your medical benefits. benefit year. Not Covered: Not Covered: ◼ Surgery and services to diagnose or ◼ Expenses of transporting the recipient correct a refractive error, including when the transplant organ for the intraocular lenses and laser vision recipient is not available for transplant. correction surgery (e.g., LASIK surgery). ◼ Expenses of transporting a living donor. ◼ Eyeglasses, contact lenses, or the ◼ Expenses related to the purchase of any examination for prescribing or fitting of organ. eyeglasses, except when prescribed as ◼ Services or supplies related to the result of cataract extraction or when mechanical or non-human organs the underlying diagnosis is a corneal associated with transplants. injury or disease. ◼ Transplant services and supplies not listed in this section including Wigs or Hairpieces complications. Not Covered. See Also: Ambulance Services earlier in this section. X-ray and Laboratory Case Management, page 57. Services Covered: Tests, screenings, imagings, and Referrals, page 45. evaluation procedures as identified in the American Medical Association's Current Travel or Lodging Costs Procedural Terminology (CPT) manual, Not Covered. Standard Edition, under Radiology Guidelines and Pathology and Laboratory Vision Services Guidelines. Covered: See Also: ◼ Routine vision and refraction Preventive Care earlier in this section. examinations and contact lens fitting.

Prescription Drugs

◼ Listed on the Wellmark Blue Rx Guidelines for Drug Coverage Complete Drug List. To be covered, a prescription drug or ◼ Can be legally obtained in the United pharmacy durable medical equipment States only with a written prescription. device must meet all of the following ◼ Deemed both safe and effective by the criteria: U.S. Food and Drug Administration (FDA) and approved for use by the FDA after 1962.

CHRXST 32 Form Number: Wellmark IA Grp/DE_ 0121 Details – Covered and Not Covered

◼ Prescribed by a practitioner prescribing available, new safety concerns arise, and as within the scope of his or her license. discontinued drugs are removed from the ◼ Dispensed by a recognized licensed marketplace. Additional changes to the participating retail pharmacy employing Drug List that could have an adverse licensed registered pharmacists, through financial impact to you (e.g., drug exclusion, the specialty pharmacy program, drug moving to a higher payment tier/level) through the mail order drug program, or occur semi-annually. dispensed and billed by a hospital or To determine if a drug is covered, you must other facility as a take-home drug for a consult the Wellmark Blue Rx Complete short-term supply. Drug List. You are covered for drugs listed ◼ Medically necessary for your condition. on the Wellmark Blue Rx Complete Drug See Medically Necessary, page 37. List. If a drug is not on the Wellmark Blue ◼ Not available in an equivalent over-the- Rx Complete Drug List, it is not covered. counter strength. However, certain over- If you need help determining if a particular the-counter products and over-the- drug is on the Drug List, ask your physician counter nicotine dependency drugs or pharmacist, visit our website, prescribed by a physician may be Wellmark.com, or call the Customer Service covered. To determine if a particular number on your ID card and request a copy over-the-counter product is covered, call of the Drug List. the Customer Service number on your ID card. The Drug List is subject to change. ◼ Reviewed, evaluated, and recommended Preventive Items and Services for addition to the Wellmark Blue Rx Preventive items and services received at a Complete Drug List by Wellmark. participating licensed retail pharmacy, including certain items or services Drugs that are Covered recommended with an “A” or “B” rating by The Wellmark Blue Rx Complete Drug the United States Preventive Services Task List Force, immunizations recommended by the The Wellmark Blue Rx Complete Drug List Advisory Committee on Immunization is a reference list that includes generic and Practices of the Centers for Disease Control brand-name prescription drugs and and Prevention, and preventive care and pharmacy durable medical equipment screenings provided for in guidelines devices that have been approved by the U.S. supported by the Health Resources and Food and Drug Administration (FDA) and Services Administration are covered. To are covered under your Blue Rx Complete determine if a particular preventive item or prescription drug benefits. The Wellmark service is covered, consult the Wellmark Blue Rx Complete Drug List is established Blue Rx Complete Drug List or call the and maintained by Wellmark’s Pharmacy & Customer Service number on your ID card. Therapeutics (P&T) Committee. The P&T Specialty Drugs Committee is an independent group of Specialty drugs are high-cost injectable, practicing healthcare providers such as oral, or inhaled drugs typically used for physicians and pharmacists who regularly treating or managing chronic illnesses. meet to review the safety, effectiveness, and These drugs often require special handling value of new and existing medications and (e.g., refrigeration) and administration. You make any necessary changes to the Drug must purchase specialty drugs through the List. The Drug List is updated on a quarterly specialty pharmacy program. They are not basis. Changes to the Drug List may occur available through the mail order drug more frequently, when new versions or program. generic versions of existing drugs become

Form Number: Wellmark IA Grp/DE_ 0121 33 CHRXST Details – Covered and Not Covered

Specialty drugs may be covered under your Limits on Prescription Drug Blue Rx Complete prescription drug benefits Coverage or under your medical benefits. To determine whether a particular specialty We may exclude, discontinue, or limit drug is covered under your Blue Rx coverage for any drug by removing it from Complete prescription drug benefits or the Drug List or by moving a drug to a under your medical benefits, consult the different tier on the Drug List for any of the Wellmark Blue Rx Complete Drug List at following reasons: Wellmark.com, check with your pharmacist ◼ New drugs are developed. or physician, or call the Customer Service ◼ Generic drugs become available. number on your ID card. See Specialty ◼ Over-the-counter drugs with similar Pharmacy Program, page 51. properties become available or a drug’s Nicotine Dependency Drugs active ingredient is available in a similar Prescription drugs and devices used to treat strength in an over-the-counter product nicotine dependence, including over-the- or as a nutritional or dietary supplement counter drugs prescribed by a physician are product available over the counter. covered. ◼ There is a sound medical reason. Benefits Maximum: 180-days' supply of ◼ Scientific evidence does not show that a covered over-the-counter drugs for smoking drug works as well and is as safe as other cessation per calendar year. drugs used to treat the same or similar conditions. Where to Purchase ◼ A drug receives FDA approval for a new Prescription Drugs use. Participating Pharmacies. You must Drugs, Services, and Items purchase prescription drugs from participating pharmacies (excluding that are Not Covered specialty drugs, which must be purchased Drugs, services, and items that are not through the specialty pharmacy program. covered under your prescription drug See Specialty Drugs, later in this section). benefits include, but are not limited to: If you purchase drugs from nonparticipating ◼ Drugs not listed on the Wellmark Blue pharmacies, you are responsible for the Rx Complete Drug List. entire cost of the drug. To determine if a ◼ Drugs purchased from nonparticipating pharmacy is participating, ask the pharmacies. pharmacist, consult the directory of ◼ Specialty drugs purchased outside the participating pharmacies on our website at specialty pharmacy program unless the Wellmark.com, or call the Customer Service specialty drug is covered under your number on your ID card. Our directory also medical benefits. is available upon request by calling the ◼ Drugs in excess of a quantity limitation. Customer Service number on your ID card. See Quantity Limitations later in this Specialty Drugs. You must purchase section. specialty drugs through the specialty ◼ Antigen therapy. pharmacy program. The specialty pharmacy ◼ Drugs that are not FDA-approved. ® program is limited to CVS Specialty . If you ◼ Drugs that are not approved to be purchase specialty drugs outside the covered by Wellmark’s P&T Committee. specialty pharmacy program, you are ◼ Investigational or experimental drugs. responsible for the entire cost of the drug. ◼ Compounded drugs that do not contain See Specialty Pharmacy Program, page 51. an active ingredient in a form that has

CHRXST 34 Form Number: Wellmark IA Grp/DE_ 0121 Details – Covered and Not Covered

been approved by the FDA and that an FDA equivalent and has the same require a prescription to obtain. name and dosage form as the FDA- ◼ Compounded drugs that contain bulk approved drug's active ingredient. powders or that are commercially ◼ The prescription drug would require a available as a similar prescription drug. written prescription by a licensed ◼ Drugs determined to be abused or practitioner if prescribed in the U.S. otherwise misused by you. ◼ You provide acceptable documentation ◼ Drugs that are lost, damaged, stolen, or that you received a covered service from used inappropriately. a practitioner or hospital and the ◼ Contraceptive medical devices, such as practitioner or hospital prescribed the intrauterine devices and diaphragms. prescription drug. These are covered under your medical benefits. See Contraceptives, page 18. Quantity Limitations ◼ Convenience packaging. If the cost of Most prescription drugs are limited to a the convenience packaged drug exceeds maximum quantity you may receive in a what the drug would cost if purchased in single prescription. its normal container, the convenience Federal regulations limit the quantity that packaged drug is not covered. may be dispensed for certain medications. If ◼ Cosmetic drugs. your prescription is so regulated, it may not ◼ Infused drugs. These may be covered be available in the amount prescribed by under your medical benefits. See your physician. Specialty Drugs, page 28. In addition, coverage for certain drugs is ◼ Irrigation solutions and supplies. limited to specific quantities per month, ◼ Medication Therapy Management benefit year, or lifetime. Amounts in excess (MTM) when billed separately. of quantity limitations are not covered. ◼ Therapeutic devices or medical For a list of drugs with quantity limits, appliances. check with your pharmacist or physician, ◼ Infertility drugs. consult the Wellmark Blue Rx Complete ◼ Weight reduction drugs. Drug List at Wellmark.com, or call the ◼ Difference in cost between the generic Customer Service number on your ID card. drug and the brand name drug when you purchase a brand name drug that Refills has an FDA-approved “A”-rated To qualify for refill benefits, all of the medically appropriate generic following requirements must be met: equivalent. ◼ Sufficient time has elapsed since the last See Also: prescription was written. Sufficient time Prescription Drugs, page 28. means that at least 75 percent of the medication has been taken according to Prescription Purchases the instructions given by the Outside the United States practitioner. To qualify for benefits for prescription drugs ◼ The refill is not to replace medications purchased outside the United States, all of that have been lost, damaged, stolen, or the following requirements must be met: used inappropriately. ◼ The refill is for use by the person for ◼ You are injured or become ill while in a whom the prescription is written (and foreign country. not someone else). ◼ The prescription drug's active ingredient and dosage form are FDA-approved or

Form Number: Wellmark IA Grp/DE_ 0121 35 CHRXST Details – Covered and Not Covered

◼ The refill does not exceed the amount authorized by your practitioner. ◼ The refill is not limited by state law. You are allowed one early refill per medication per calendar year if you will be away from home for an extended period of time. If traveling within the United States, the refill amount will be subject to any applicable quantity limits under this coverage. If traveling outside the United States, the refill amount will not exceed a 90-day supply. To receive authorization for an early refill, ask your pharmacist to call us.

CHRXST 36 Form Number: Wellmark IA Grp/DE_ 0121

4. General Conditions of Coverage, Exclusions, and Limitations

The provisions in this section describe ⎯ Wellmark’s published Medical and general conditions of coverage and Drug Policies as determined important exclusions and limitations that applicable by Wellmark; or apply generally to all types of services or ⎯ Credible scientific evidence supplies. published in peer-reviewed medical literature generally recognized by Conditions of Coverage the relevant medical community; or Medically Necessary ⎯ Physician Specialty Society A key general condition in order for you to recommendations and the views of receive benefits is that the service, supply, physicians practicing in the relevant device, or drug must be medically necessary. clinical area. Even a service, supply, device, or drug listed ◼ Clinically appropriate in terms of type, as otherwise covered in Details - Covered frequency, extent, site and duration, and and Not Covered may be excluded if it is not considered effective for the patient’s medically necessary in the circumstances. illness, injury or disease, Unless otherwise required by law, Wellmark ◼ Not provided primarily for the determines whether a service, supply, convenience of the patient, physician, or device, or drug is medically necessary, and other health care provider, and that decision is final and conclusive. ◼ Not more costly than an alternative Wellmark’s medically necessary analysis service or sequence of services at least as and determinations apply to any service, likely to produce equivalent therapeutic supply, device, or drug including, but not or diagnostic results as to the diagnosis limited to, medical, mental health, and or treatment of the illness, injury or chemical dependency treatment, as disease. appropriate. Even though a provider may An alternative service, supply, device, or recommend a service or supply, it may not drug may meet the criteria of medical be medically necessary. necessity for a specific condition. If A medically necessary health care service is alternatives are substantially equal in one that a provider, exercising prudent clinical effectiveness and use similar clinical judgment, provides to a patient for therapeutic agents or regimens, we reserve the purpose of preventing, evaluating, the right to approve the least costly diagnosing or treating an illness, injury, alternative. disease or its symptoms, and satisfies all of If you receive services that are not medically the following criteria: necessary, you are responsible for the cost ◼ Provided in accordance with generally if:

accepted standards of medical practice. ◼ You receive the services from an Out-of- Generally accepted standards of medical Network Provider; or practice are based on: ◼ You receive the services from a ⎯ Nationally recognized utilization Wellmark Blue POS or Participating management standards as utilized provider and: by Wellmark; or ⎯ The provider informs you in writing before rendering the services that

Form Number: Wellmark IA Grp/GC_ 0121 37 CHRXST General Conditions of Coverage, Exclusions, and Limitations

Wellmark determined the services to product, or drug is considered be not medically necessary; and investigational or experimental is applied to ⎯ The provider gives you a written medical, surgical, mental health, and estimate of the cost for such services chemical dependency treatment services, as and you agree in writing, before applicable. receiving the services, to assume the To determine investigational or payment responsibility. experimental status, we may refer to the If you do not receive such a written technical criteria established by the Blue notice, and do not agree in writing to Cross Blue Shield Association, including assume the payment responsibility for whether a service, supply, device, biological services that Wellmark determined are product, or drug meets these criteria: not medically necessary, the Wellmark ◼ It has final approval from the Blue POS or Participating provider is appropriate governmental regulatory responsible for these amounts. bodies. ◼ You are also responsible for the cost if ◼ The scientific evidence must permit you receive services from an Out-of- conclusions concerning its effect on Network Provider that Wellmark health outcomes. determines to be not medically ◼ It improves the net health outcome. necessary. This is true even if the provider does not give you any written ◼ It is as beneficial as any established notice before the services are rendered. alternatives. ◼ The health improvement is attainable Member Eligibility outside the investigational setting. Another general condition of coverage is These criteria are considered by the Blue that the person who receives services must Cross Blue Shield Association's Medical meet requirements for member eligibility. Advisory Panel for consideration by all Blue See Coverage Eligibility and Effective Date, Cross and Blue Shield member page 67. organizations. While we may rely on these criteria, the final decision remains at the General Exclusions discretion of our Medical Director, whose Even if a service, supply, device, or drug is decision may include reference to, but is not listed as otherwise covered in Details - controlled by, policies or decisions of other Covered and Not Covered, it is not eligible Blue Cross and Blue Shield member for benefits if any of the following general organizations. You may access our medical exclusions apply. policies, with supporting information and selected medical references for a specific Investigational or Experimental service, supply, device, biological product, You are not covered for a service, supply, or drug through our website, device, biological product, or drug that is Wellmark.com. investigational or experimental. You are also not covered for any care or treatments If you receive services that are related to the use of a service, supply, investigational or experimental, you are device, biological product, or drug that is responsible for the cost if: investigational or experimental. A treatment ◼ You receive the services from an Out-of- is considered investigational or Network Provider; or experimental when it has progressed to ◼ You receive the services from a limited human application but has not Wellmark Blue POS or Participating achieved recognition as being proven provider and: effective in clinical medicine. Our analysis of whether a service, supply, device, biological

CHRXST 38 Form Number: Wellmark IA Grp/GC_ 0121 General Conditions of Coverage, Exclusions, and Limitations

⎯ The provider informs you in writing services (such as interpretive services, pre- before rendering the services that care assessments, health risk assessments, Wellmark determined the services to case management, care coordination, or be investigational or experimental; development of treatment plans) when and billed separately, and any services or ⎯ The provider gives you a written supplies that are nonmedical. estimate of the cost for such services Provider Is Family Member and you agree in writing, before You are not covered for a service or supply receiving the services, to assume the received from a provider who is in your payment responsibility. immediate family (which includes yourself, If you do not receive such a written parent, child, or spouse or domestic notice, and do not agree in writing to partner). assume the payment responsibility for services that Wellmark determined to be Covered by Other Programs or Laws investigational or experimental, the You are not covered for a service, supply, Wellmark Blue POS or Participating device, or drug if: provider is responsible for these ◼ Someone else has the legal obligation to amounts. pay for services, has an agreement with ◼ You are also responsible for the cost if you to not submit claims for services or, you receive services from an Out-of- without this group health plan, you Network Provider that Wellmark would not be charged. determines to be investigational or ◼ You require services or supplies for an experimental. This is true even if the illness or injury sustained while on provider does not give you any written active military status. notice before the services are rendered. See Also: Workers’ Compensation You are not covered for services or supplies Clinical Trials, page 17. for which we learn or are notified by you, your provider, or our vendor that such Complications of a Noncovered Service services or supplies are related to a work You are not covered for a complication related illness or injury, including services resulting from a noncovered service, supply, or supplies applied toward satisfaction of device, or drug. However, this exclusion any deductible under your employer’s does not apply to the treatment of workers’ compensation coverage. We will complications resulting from: comply with our statutory obligation regarding payment on claims on which ◼ Smallpox vaccinations when payment workers’ compensation liability is for such treatment is not available unresolved. You are also not covered for any through workers’ compensation or services or supplies that could have been government-sponsored programs; or compensated under workers’ compensation ◼ A noncovered abortion. laws if: Nonmedical or Administrative ◼ you did not comply with the legal Services requirements relating to notice of injury, You are not covered for telephone timely filing of claims, and medical consultations, charges for failure to keep treatment authorization; or scheduled appointments, charges for ◼ you rejected workers’ compensation completion of any form, charges for medical coverage. information, recreational therapy and other The exclusion for services or supplies sensory-type activities, administrative related to work related illness or injury does

Form Number: Wellmark IA Grp/GC_ 0121 39 CHRXST General Conditions of Coverage, Exclusions, and Limitations not exclude coverage for such illness or Benefits Maximums, page 7, and At a injury if you are exempt from coverage Glance–Covered and Not Covered, page under Iowa’s workers’ compensation 11. statutes pursuant to Iowa Code Section 85.1 ◼ If you do not obtain precertification for (1)-(4), unless you or your employer has certain medical services, benefits can be elected or obtained workers’ compensation denied. You are responsible for benefit coverage as provided in Iowa Code Section denials only if you are responsible (not 85.1(6). your provider) for notification. A For treatment of complications resulting Wellmark Blue POS Provider in the from smallpox vaccinations, see Wellmark Blue POS network will handle Complications of a Noncovered Service notification requirements for you. If you earlier in this section. see a provider outside the Wellmark Blue POS network, you are responsible Wellmark Medical and Drug Policies for notification requirements. See Wellmark maintains Medical and Drug Notification Requirements and Care Policies that are applied in conjunction with Coordination, page 53. other resources to determine whether a ◼ If you do not obtain prior approval for specific service, supply, device, biological certain medical services, benefits will be product, or drug is a covered service under denied on the basis that you did not the terms of this coverage manual. These obtain prior approval. Upon receiving an policies are hereby incorporated into this Explanation of Benefits (EOB) coverage manual. You may access these indicating a denial of benefits for failure policies along with supporting information to request prior approval, you will have and selected medical references through our the opportunity to appeal (see the website, Wellmark.com. Appeals section) and provide us with medical information for our Benefit Limitations consideration in determining whether Benefit limitations refer to amounts for the services were medically necessary which you are responsible under this group and a benefit under your medical health plan. These amounts are not credited benefits. Upon review, if we determine toward your out-of-pocket maximum. In the service was medically necessary and addition to the exclusions and conditions a benefit under your medical benefits, described earlier, the following are benefits for that service will be provided examples of benefit limitations under this according to the terms of your medical group health plan: benefits.

◼ A service or supply that is not covered You are responsible for these benefit under this group health plan is your denials only if you are responsible (not responsibility. your provider) for notification. A ◼ If a covered service or supply reaches a Wellmark Blue POS Provider in the benefits maximum, it is no longer Wellmark Blue POS network will handle eligible for benefits. (A maximum may notification requirements for you. If you renew at the next benefit year.) See see a provider outside the Wellmark Details – Covered and Not Covered, Blue POS network, you are responsible page 15. for notification requirements. See Notification Requirements and Care ◼ If you receive benefits that reach a Coordination, page 53. lifetime benefits maximum applicable to any specific service, then you are no ◼ If you do not obtain prior authorization longer eligible for benefits for that for certain prescription drugs, benefits service under this group health plan. See can be denied. See Notification

CHRXST 40 Form Number: Wellmark IA Grp/GC_ 0121 General Conditions of Coverage, Exclusions, and Limitations

Requirements and Care Coordination, page 53. ◼ The type of provider you choose can affect your benefits and what you pay. See Choosing a Provider, page 43, and Factors Affecting What You Pay, page 59. An example of a charge that depends on the type of provider includes, but is not limited to: ⎯ Any difference between the provider’s amount charged and our amount paid is your responsibility if you receive services from an Out-of- Network Provider.

Form Number: Wellmark IA Grp/GC_ 0121 41 CHRXST

5. Choosing a Provider

Medical This level offers the lowest payment for Provider Network benefits. Under the medical benefits of this plan, There may be exceptions for certain covered your network of providers consists of services. These exceptions are explained in Wellmark Blue POS and Participating What You Pay, page 3. providers, including your designated personal doctor. All other providers are not It is usually to your advantage to receive in your network. See Designated Personal services from your designated personal Doctor later in this section. Which provider doctor or a Wellmark Blue POS Provider. If type you choose will affect what you pay. you are unable to utilize a Wellmark Blue POS Provider, we recommend you receive Providers who do not participate with the services from a Participating Provider. network utilized by these medical benefits Although you may pay more for services you are called Out-of-Network Providers. receive from a Participating Provider, you Blue Choice allows you to receive covered will usually pay the most for services services from almost any provider who is received from an Out-of-Network Provider. eligible to provide the services. However, Participating Providers participate with a there are different levels of benefits Blue Cross and/or Blue Shield Plan, but not depending on the type of provider you use: with the Wellmark Blue POS network. Level 1 – Generally, you will receive this To determine if a provider participates with payment level when: this medical benefits plan, ask your ◼ You receive services from your provider, refer to our online provider designated personal doctor. directory at Wellmark.com, or call the ◼ You receive services from a Wellmark Customer Service number on your ID card. Blue POS chiropractor. Our provider directory is also available upon request by calling the Customer Service ◼ You receive services from a Wellmark number on your ID card. Blue POS occupational therapist. ◼ You receive services from a Wellmark Providers are independent contractors and Blue POS physical therapist. are not agents or employees of Wellmark ◼ You receive services from a Wellmark Health Plan of Iowa, Inc. For types of Blue POS speech pathologist. providers that may be covered under your medical benefits, see Hospitals and ◼ You receive services from a Wellmark Facilities, page 22 and Physicians and Blue POS network facility. Practitioners, page 27. Level 2 – Generally, you will receive this payment level when you do not receive Please note: Even if a specific provider services from your designated personal type is not listed as a recognized provider doctor, but receive services from a type, Wellmark does not discriminate Wellmark Blue POS Provider. against a licensed health care provider acting within the scope of his or her state Level 3 – Generally, you will receive this license or certification with respect to payment level when you do not receive coverage under this plan. services from your designated personal doctor or a Wellmark Blue POS Provider. Please note: Even though a facility may be a Wellmark Blue POS network facility,

Form Number: Wellmark IA Grp/CP_ 0121 43 CHRXST Choosing a Provider particular providers within the facility may Pharmacies that contract with our not be Wellmark Blue POS Providers. pharmacy benefits manager are considered Examples include Out-of-Network Participating Providers. Pharmacies that do physicians on the staff of a Wellmark Blue not contract with our pharmacy benefits POS network hospital, home medical manager are considered Out-of-Network equipment suppliers, and other Providers. To determine if a pharmacy independent providers. Therefore, when you contracts with our pharmacy benefits are referred by a Wellmark Blue POS manager, ask the pharmacist, consult the Provider to another provider, or when you directory of participating pharmacies on our are admitted into a facility, always ask if the website at Wellmark.com, or call the providers are Wellmark Blue POS Providers. Customer Service number on your ID card. See Choosing a Pharmacy and Specialty Always carry your ID card and present it Pharmacy Program later in this section. when you receive services. Information on it, especially the ID number, is required to process your claims correctly.

Provider Comparison Chart

Network

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of

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DesignatedPersonal Doctorand Level 1 Providers WellmarkBlue POS Providers Participating Out

Accepts Blue Cross and/or Blue Shield payment Yes Yes Yes No arrangements. Minimizes your payment obligations. See What You Pay, Yes Yes No No page 3. Claims are filed for you. Yes Yes Yes No Blue Cross and/or Blue Shield pays these providers directly. Yes Yes Yes No Notification requirements are handled for you. Yes Yes Yes* No *If you are admitted to a Participating facility outside the Wellmark Blue POS network, Participating Providers should handle notification requirements for you. ◼ Physician Assistants Designated Personal Doctor ◼ Pediatricians Your designated personal doctor, which may All covered family members must select a also be referred to as your designated PCP, personal doctor for claims to be paid, evaluates your medical condition and either including covered family members who live treats your condition or coordinates services outside the network area (for example, you require. You must choose a personal college students). Each member may choose doctor who participates in the Wellmark his or her own personal doctor. For a Blue POS network and who is available to covered child, you may choose a accept you or your covered family members. pediatrician as the designated personal You may select one of the following types of doctor. providers as your designated personal If your designated personal doctor is not doctor: available, he or she will designate a backup ◼ General/Family Practice Physicians provider. When you receive covered services from a backup provider, you will receive the ◼ Internists same level of benefits as when you visit your ◼ Nurse Practitioners personal doctor.

CHRXST 44 Form Number: Wellmark IA Grp/CP_ 0121 Choosing a Provider

If your designated personal doctor leaves Chiropractic Services the Wellmark Blue POS network, you will be You will receive Benefit Level 1 when you notified and required to choose another receive covered chiropractic services from a personal doctor. Wellmark Blue POS chiropractor. For information on how to select a personal doctor or for a list of participating personal Occupational Therapy, doctors, call the Customer Service number Physical Therapy, and Speech on your ID card or visit our website, Therapy Wellmark.com. You will receive Benefit Level 1 when you Changing Your Designated Personal receive covered services from a Wellmark Doctor. If you or a covered family member Blue POS: decides to switch to a different designated ◼ Occupational therapist. personal doctor or OB/GYN, submit a ◼ Physical therapist. change form, or call the Customer Service ◼ Speech pathologist. number on your ID card. Changes will be in effect by the first day of the month following Preventive Care receipt of your request. It is usually to your advantage to receive Obstetrical/Gynecological (OB/GYN) preventive care from your designated Services. Female members may receive personal doctor or your designated OB/GYN gynecological services from their designated care provider. The following preventive personal doctor or choose an services must be provided by your obstetrical/gynecological (OB/GYN) care designated personal doctor to be covered: provider from the Wellmark Blue POS network. ◼ Preventive Physical Examination. ◼ Preventive Gynecological You do not need consent from us or a Examination. You may receive your personal doctor in order to obtain preventive gynecological examination obstetrical or gynecological services from a from your designated personal doctor or Wellmark Blue POS practitioner who your selected OB/GYN. specializes in obstetrics or gynecology. ◼ Well-Child Examination. However, the practitioner may be required to comply with certain procedures, such as Vision Examinations obtaining prior approval or precertification You may receive vision examinations from a for certain services, following a case Wellmark Blue POS optometrist or management plan, or procedures for Wellmark Blue POS ophthalmologist. making referrals. You will receive Benefit Level 1 when you Referrals receive maternity care or a preventive If you require services from a provider other gynecological examination from your than your designated personal doctor, designated OB/GYN provider. However, typically a specialist, you may see a provider when you receive services other than your in the Wellmark Blue POS network. If there preventive gynecological examination from are no providers in the Wellmark Blue POS a Wellmark Blue POS OB/GYN care network who can treat your condition, you provider, you will receive Benefit Level 2. will be referred to a provider outside the For a list of Wellmark Blue POS Wellmark Blue POS network who has practitioners who specialize in obstetrics or expertise in diagnosing and treating your gynecology, call the Customer Service condition. Wellmark must approve referrals number on your ID card or visit our website, outside of the Wellmark Blue POS network Wellmark.com. before you receive services in order to Form Number: Wellmark IA Grp/CP_ 0121 45 CHRXST Choosing a Provider receive Benefit Level 2. Otherwise, you will Participating Providers in any state, call receive Benefit Level 3. Please note: Even 800-810-BLUE, or visit www.bcbs.com. when your referral outside the Wellmark When you receive covered services from Blue POS network is approved, you are still Participating Providers outside the responsible for complying with notification Wellmark Blue POS network, all of the requirements. See Notification following statements are true: Requirements and Care Coordination, page 53. Please note: Even when your referral ◼ Claims are filed for you. outside the Wellmark Blue POS network is ◼ These providers agree to accept payment approved, you may be responsible for the arrangements or negotiated prices of the difference between the amount an Out-of- Blue Cross and/or Blue Shield Plan with Network Provider bills and our payment which the provider contracts. These amount. payment arrangements may result in savings. Services Outside the ◼ The group health plan payment is sent Wellmark Blue POS Network directly to the providers. ◼ Wellmark requires claims to be filed BlueCard Program within 180 days following the date of This program ensures that members of any service. However, if the Participating Blue Plan have access to the advantages of Provider’s contract with the Host Blue Participating Providers throughout the has a requirement that a claim be filed United States. Participating Providers have in a timeframe exceeding 180 days a contractual arrangement with the Blue following the date of service, Wellmark Cross or Blue Shield Plan in their home will process the claim according to the state (“Host Blue”). The Host Blue is Host Blue’s contractual filing responsible for contracting with and requirement. If you receive services generally handling all interactions with its from an Out-of-Network Provider, the Participating Providers. claim has to be filed within 180 days The BlueCard Program is one of the following the date of service. advantages of your coverage with Wellmark Typically, when you receive covered services Health Plan of Iowa, Inc. It provides from Participating Providers outside the conveniences and benefits outside the Wellmark Blue POS network, you are Wellmark Blue POS network area similar to responsible for notification requirements. those you would have in the Wellmark Blue See Notification Requirements and Care POS network area when you obtain covered Coordination, page 53. However, if you are medical services from a Wellmark Blue POS admitted to a BlueCard facility outside the Provider. Always carry your ID card (or Wellmark Blue POS network, any BlueCard) and present it to your provider Participating Provider should handle when you receive care. Information on it, notification requirements for you. especially the ID number, is required to Wellmark Health Plan of Iowa, Inc., is an process your claims correctly. affiliate of Wellmark, Inc., doing business as In an emergency situation, seek care at the Wellmark Blue Cross and Blue Shield of nearest hospital emergency room. Iowa, independent licensees of the Blue Whenever possible, before receiving services Cross Blue Shield Association. We have a outside the Wellmark Blue POS network, variety of relationships with other Blue you should always ask the provider if he or Cross and/or Blue Shield Plans and their she participates with a Blue Cross and/or Licensed Controlled Affiliates (“Licensees”). Blue Shield Plan in that state. To locate Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-

CHRXST 46 Form Number: Wellmark IA Grp/CP_ 0121 Choosing a Provider

Plan Arrangements work based on rules and notification requirements may apply, See procedures issued by the Blue Cross Blue Notification Requirements and Care Shield Association (“Association”). Coordination, page 53. Whenever you obtain healthcare services Emergency Care Services: If you outside the Wellmark Blue POS network, experience a medical emergency while the claims for these services may be traveling outside the Wellmark Blue POS processed through one of these Inter-Plan network, go to the nearest emergency or Arrangements. urgent care facility. When you receive care outside of our service When you receive covered out-of-area area, you will receive it from one of two services outside our service area and the kinds of providers. Most providers claim is processed through the BlueCard (“Participating Providers”) contract with the Program, the amount you pay for the local Blue Cross and/or Blue Shield Plan in covered out-of-area services, if not a flat that geographic area (“Host Blue”). Some dollar copayment, is calculated based on the providers (“Out-of-Network Providers”) lower of: don’t contract with the Host Blue. In the following paragraphs we explain how we ◼ The billed charges for your out-of-area pay both kinds of providers. covered services; or ◼ The negotiated price that the Host Blue Inter-Plan Arrangements Eligibility – makes available to us. Claim Types Often, this “negotiated price” will be a All claim types are eligible to be processed simple discount that reflects an actual price through Inter-Plan Arrangements, as that the Host Blue pays to your healthcare described previously, except for all dental provider. Sometimes, it is an estimated care benefits (except when paid as medical price that takes into account special benefits), and those prescription drug arrangements with your healthcare provider benefits or vision care benefits that may be or provider group that may include types of administered by a third party contracted by settlements, incentive payments and/or us to provide the specific service or services. other credits or charges. Occasionally, it BlueCard® Program may be an average price, based on a Under the BlueCard® Program, when you discount that results in expected average receive out-of-area covered services within savings for similar types of healthcare the geographic area served by a Host Blue, providers after taking into account the same we will remain responsible for doing what types of transactions as with an estimated we agreed to in the contract. However, the price. Host Blue is responsible for contracting Estimated pricing and average pricing also with and generally handling all interactions take into account adjustments to correct for with its Participating Providers. over- or underestimation of modifications of The BlueCard Program enables you to past pricing of claims, as noted previously. obtain covered out-of-area services, as However, such adjustments will not affect defined previously in this section, from a the price we have used for your claim healthcare provider participating with a because they will not be applied after a Host Blue, where available. The claim has already been paid. Participating Provider will automatically file a claim for the covered out-of-area services Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees provided to you, so there are no claim forms Federal or state laws or regulations may for you to fill out. You will be responsible for require a surcharge, tax, or other fee that your payment obligations. See Referrals applies to insured accounts. If applicable, earlier in this section. In addition we will include any such surcharge, tax, or

Form Number: Wellmark IA Grp/CP_ 0121 47 CHRXST Choosing a Provider other fee as part of the claim charge passed you may also be entitled to benefits for some on to you. services obtained outside the Wellmark Blue POS network, even though you might not Out-of-Network Providers Outside the otherwise have been entitled to benefits if Wellmark Service Area you had received those services inside the Your Liability Calculation. When Wellmark Blue POS network. But in no covered out-of-area services are provided event will you be entitled to benefits for outside of our service area by Out-of- services, wherever you received them, that Network Providers, the amount you pay for are specifically excluded from, or in excess such services will normally be based on of the limits of, coverage provided by your either the Host Blue’s Out-of-Network medical benefits. Provider local payment or the pricing arrangements required by applicable state Care in a Foreign Country law. In these situations, you may be For covered services you receive in a responsible for the difference between the country other than the United States, amount that the Out-of-Network Provider payment level assumes the provider bills and the payment we will make for the category is Out-of-Network except for covered out-of-area services as set forth in services received from providers that this coverage manual. Federal or state law, participate with Blue Cross Blue Shield as applicable, will govern payments for Out- Global Core. of-Network emergency services. Blue Cross Blue Shield Global® Core In certain situations, we may use other Program payment methods, such as billed charges for If you are outside the United States, the covered out-of-area services, the payment Commonwealth of Puerto Rico, and the U.S. we would make if the healthcare services Virgin Islands, you may be able to take had been obtained within our service area, advantage of the Blue Cross Blue Shield or a special negotiated payment to Global Core Program when accessing determine the amount we will pay for covered services. The Blue Cross Blue Shield services provided by Out-of-Network Global Core Program is unlike the BlueCard Providers. In these situations, you may be Program available in the United States, the liable for the difference between the amount Commonwealth of Puerto Rico, and the U.S. that the Out-of-Network Provider bills and Virgin Islands in certain ways. For instance, the payment we will make for the covered although the Blue Cross Blue Shield Global out-of-area services as set forth in this Core Program assists you with accessing a coverage manual. network of inpatient, outpatient, and professional providers, the network is not Change of Residence served by a Host Blue. As such, when you You must notify us prior to relocating receive care from providers outside the outside the Wellmark Health Plan of Iowa, United States, the Commonwealth of Puerto Inc., geographic service area because you Rico, and the U.S. Virgin Islands, you will will have no benefits for medical or typically have to pay the providers and laboratory services provided outside of submit the claims yourself to obtain Wellmark Health Plan of Iowa, Inc.’s reimbursement for these services. provider network except for emergencies or accidental injuries. If you need medical assistance services (including locating a doctor or hospital) You are entitled to benefits for services that outside the United States, the you receive either inside or outside the Commonwealth of Puerto Rico, and the U.S. Wellmark Blue POS network if your medical Virgin Islands, you should call the Blue benefits covers those services. Due to Cross Blue Shield Global Core Service variations in Host Blue network protocols,

CHRXST 48 Form Number: Wellmark IA Grp/CP_ 0121 Choosing a Provider

Center at 800-810-BLUE (2583) or call assistance with your claim submission, you collect at 804-673-1177, 24 hours a day, should call the Blue Cross Blue Shield seven days a week. An assistance Global Core Service Center at 800-810- coordinator, working with a medical BLUE (2583) or call collect at 804-673- professional, can arrange a physician 1177, 24 hours a day, seven days a week. appointment or hospitalization, if necessary. You are eligible for Benefit Level 1 for Inpatient Services. In most cases, if you covered services received from Out-of- contact the Blue Cross Blue Shield Global Network or Participating providers Core Service Center for assistance, hospitals (including out-of-country providers) only in will not require you to pay for covered the following situations: inpatient services, except for your ◼ Accidental Injuries. deductibles, coinsurance, etc. In such cases, ◼ Emergencies. If you cannot the hospital will submit your claims to the reasonably reach a Wellmark Blue POS Blue Cross Blue Shield Global Core Service Provider, it is in your best interest to Center to begin claims processing. However, seek care from a Participating Provider. if you paid in full at the time of service, you must submit a claim to receive Participating Providers participate with reimbursement for covered services. You a Blue Cross and/or Blue Shield Plan, must contact us to obtain but not with the Wellmark Blue POS precertification for non-emergency network. inpatient services. Out-of-Network Providers do not Outpatient Services. Physicians, urgent participate with this plan or any other care centers and other outpatient providers Blue Cross and/or Blue Shield Plan. located outside the United States, the For information on how benefits for Commonwealth of Puerto Rico, and the U.S. accidental injuries and emergency Virgin Islands will typically require you to services will be administered when pay in full at the time of service. You must received outside of the Wellmark Blue submit a claim to obtain reimbursement for POS network, see BlueCard Program covered services. See Claims, page 75. earlier in this section and Out-of- Network Providers, page 61. Submitting a Blue Cross Blue Shield Global Core Claim When you receive covered services for When you pay for covered services outside emergency medical conditions from the United States, the Commonwealth of Out-of-Network Providers, all of the Puerto Rico, and the U.S. Virgin Islands, following statements are true: you must submit a claim to obtain ⎯ Out-of-Network Providers are not reimbursement. For institutional and responsible for filing your claims. professional claims, you should complete a Blue Cross Blue Shield Global Core ⎯ We do not have contracts with Out- International claim form and send the claim of-Network Providers and they may form with the provider’s itemized bill(s) to not agree to accept our payment the Blue Cross Blue Shield Global Core arrangements. Therefore, you are Service Center (the address is on the form) responsible for any difference to initiate claims processing. Following the between the amount charged and instructions on the claim form will help our payment. ensure timely processing of your claim. The ⎯ We make claims payments to you, claim form is available from us, the Blue not Out-of-Network Providers. Cross Blue Shield Global Core Service ⎯ You are responsible for notification Center, or online at requirements. www.bcbsglobalcore.com. If you need

Form Number: Wellmark IA Grp/CP_ 0121 49 CHRXST Choosing a Provider

◼ Continuity of Care. You may be attending college out of state, or covered eligible to continue care from an Out-of- family members living apart are eligible to Network Provider for treatment of a become a guest member any time they are terminal illness, a complex medical outside the Wellmark Blue POS network condition, or during the second or third area for at least 90 days. Not all services trimester of pregnancy if: covered under your medical benefits are ⎯ You had been receiving care for the covered under Guest Membership. To condition from a Wellmark Blue POS determine which services are covered under Provider but the provider’s contract the Guest Membership program, call us. with us terminates; or To receive covered services under the Guest ⎯ You were previously covered by a Membership program, you must receive the different carrier or plan and had service(s) from a Participating Provider. been receiving care for the condition from an Out-of-Network Provider Before you leave the Wellmark Blue POS network area, call the Customer Service when you begin coverage under your medical benefits. number on your ID card to set up a guest membership. If either situation applies, you may continue Out-of-Network treatment as Laboratory services. You may have follows: laboratory specimens or samples collected by a Wellmark Blue POS Provider and those ⎯ Terminal illness (as determined by laboratory specimens may be sent to the provider): for 90 days after the another laboratory services provider for provider’s contract terminates or the processing or testing. If that laboratory patient begins coverage with services provider does not have a Wellmark while under the care of an contractual relationship with the Blue Plan Out-of-Network Provider for where the specimen was drawn,* Benefit treatment of the terminal illness, Level 3 may apply and you may also be whichever applies. responsible for any difference between the ⎯ Complex medical condition: for a amount charged and our amount paid for time period or benefit maximum the covered service. determined by medical management. You or your provider *Where the specimen is drawn will be must notify us before receiving determined by which state the referring services under these medical provider is located. benefits, and the medical condition Home/durable medical equipment. If must warrant continued treatment you purchase or rent home/durable medical by the Out-of-Network Provider. equipment from a provider that does not ⎯ Pregnancy in second or third have a contractual relationship with the trimester: through postpartum care Blue Plan where you purchased or rented related to the childbirth and the equipment, Benefit Level 3 may apply delivery. and you may also be responsible for any To assist you in making a transition to a difference between the amount charged and Wellmark Blue POS Provider, you or our amount paid for the covered service. your provider must call us at 800-552- If you purchase or rent home/durable 3993. medical equipment and have that ◼ Referrals. See Referrals earlier in this equipment shipped to a service area of a section. Blue Plan that does not have a contractual Guest Membership. Members traveling relationship with the home/durable medical long-term, any covered dependents equipment provider, Benefit Level 3 may apply and you may also be responsible for

CHRXST 50 Form Number: Wellmark IA Grp/CP_ 0121 Choosing a Provider any difference between the amount charged amount charged and our amount paid for and our amount paid for the covered the covered service. This includes situations service. This includes situations where you where you purchase prosthetic devices and purchase or rent home/durable medical have them shipped to you in the Wellmark equipment and have the equipment shipped Blue POS network, when Wellmark does not to you in the Wellmark Blue POS network, have a contractual relationship with the when Wellmark does not have a contractual provider. relationship with the home/durable medical Talk to your provider. Whenever equipment provider. possible, before receiving laboratory Prosthetic devices. If you purchase services, home/durable medical equipment, prosthetic devices from a provider that does or prosthetic devices, ask your provider to not have a contractual relationship with the utilize a provider that has a contractual Blue Plan where you purchased the arrangement with the Blue Plan where you prosthetic devices, Benefit Level 3 may received services, purchased or rented apply and you may also be responsible for equipment, or shipped equipment, or ask any difference between the amount charged your provider to utilize a provider that has a and our amount paid for the covered contractual arrangement with Wellmark. service. To determine if a provider has a contractual If you purchase prosthetic devices and have arrangement with a particular Blue Plan or that equipment shipped to a service area of with Wellmark, call the Customer Service a Blue Plan that does not have a contractual number on your ID card or visit our website, relationship with the provider, Benefit Level Wellmark.com. 3 may apply and you may also be See Out-of-Network Providers, page 61. responsible for any difference between the

Prescription Drugs is available upon request by calling the Choosing a Pharmacy Customer Service number on your ID card. Your prescription drug benefits are called Blue Rx Complete. Pharmacies that Always Present Your ID Card participate with the network used by Blue If you do not have your ID card with you Rx Complete are called participating when you fill a prescription at a pharmacies. Pharmacies that do not participating pharmacy, the pharmacist may participate with the network are called not be able to access your benefit nonparticipating pharmacies. information. In this case: You must purchase prescription drugs from ◼ You must pay the full amount charged at participating pharmacies (excluding the time you receive your prescription, specialty drugs, which must be purchased and the amount we reimburse you may through the specialty pharmacy program. be less than what you paid. You are See Specialty Pharmacy Program later in responsible for this difference. this section). If you purchase drugs from ◼ You must file your claim to be nonparticipating pharmacies, you are reimbursed. See Claims, page 75. responsible for the entire cost of the drug. Specialty Pharmacy Program To determine if a pharmacy is participating, Specialty pharmacies deliver specialty drugs ask the pharmacist, consult the directory of directly to your home or to your physician's participating pharmacies on our website at office. You must purchase specialty drugs Wellmark.com, or call the Customer Service through the specialty pharmacy program. number on your ID card. Our directory also The specialty pharmacy program is limited

Form Number: Wellmark IA Grp/CP_ 0121 51 CHRXST Choosing a Provider to CVS Specialty®. You must register as a specialty pharmacy program user in order to fill your prescriptions through the specialty pharmacy program. For information on how to register, call the Customer Service number on your ID card or visit our website at Wellmark.com. You are not covered for specialty drugs purchased outside the specialty pharmacy program unless the specialty drug is covered under your medical benefits. The specialty pharmacy program administers the distribution of specialty drugs to the home and to physicians' offices. Mail Order Drug Program You must purchase mail order drugs through the mail order drug program. You are not covered for mail order drugs purchased outside the mail order drug program. You must register as a mail service user in order to fill your prescriptions through the mail order drug program. For information on how to register, visit our website, Wellmark.com, or call the Customer Service number on your ID card. Mail order pharmacy providers outside our mail order program are considered nonparticipating pharmacies. You are not covered for drugs purchased from nonparticipating mail order pharmacies. See Participating vs. Nonparticipating Pharmacies, page 65.

CHRXST 52 Form Number: Wellmark IA Grp/CP_ 0121

6. Notification Requirements and Care Coordination

Medical Many services including, but not limited to, medical, surgical, mental health, and chemical dependency treatment services, require a notification to us or a review by us. If you do not follow notification requirements properly, you may have to pay for services yourself, so the information in this section is critical. For a complete list of services subject to notification or review, visit Wellmark.com or call the Customer Service number on your ID card.

Providers and Notification Requirements Providers in the Wellmark Blue POS network should handle notification requirements for you. If you are admitted to a Participating facility outside the Wellmark Blue POS network, the Participating Provider should handle notification requirements for you. If you receive any other covered services (i.e., services unrelated to an inpatient admission) from a Participating Provider outside the Wellmark Blue POS network, or if you see an Out-of- Network Provider, you or someone acting on your behalf is responsible for notification requirements. More than one of the notification requirements and care coordination programs described in this section may apply to a service. Any notification or care coordination decision is based on the medical benefits in effect at the time of your request. If your coverage changes for any reason, you may be required to repeat the notification process. You or your authorized representative, if you have designated one, may appeal a denial of benefits resulting from these notification requirements and care coordination programs. See Appeals, page 85. Also see Authorized Representative, page 95. Precertification Purpose Precertification helps determine whether a service or admission to a facility is medically necessary. Precertification is required; however, it does not apply to maternity or emergency services. Applies to For a complete list of the services subject to precertification, visit Wellmark.com or call the Customer Service number on your ID card.

Form Number: Wellmark IA Grp/NR_ 0121 53 CHRXST Notification Requirements and Care Coordination

Person You or someone acting on your behalf is responsible for obtaining Responsible precertification if: for Obtaining Precertification ◼ You receive services subject to precertification from an Out-of-Network Provider; or ◼ You receive non-inpatient services subject to precertification from a Participating Provider outside the Wellmark Blue POS network. Your Provider should obtain precertification for you if:

◼ You receive services subject to precertification from a Wellmark Blue POS Provider in Iowa; or ◼ You receive inpatient services subject to precertification from a Participating Provider outside the Wellmark Blue POS network. Please note: If you are ever in doubt whether precertification has been obtained, call the Customer Service number on your ID card. Process When you, instead of your provider, are responsible for precertification, call the phone number on your ID card before receiving services. Wellmark will respond to a precertification request within:

◼ 72 hours in a medically urgent situation; ◼ 15 days in a non-medically urgent situation. Precertification requests must include supporting clinical information to determine medical necessity of the service or admission. After you receive the service(s), Wellmark may review the related medical records to confirm the records document the services subject to the approved precertification request. The medical records also must support the level of service billed and document that the services have been provided by the appropriate personnel with the appropriate level of supervision. Importance If you choose to receive services subject to precertification, you will be responsible for the charges as follows:

◼ If you receive services subject to precertification from an Out-of-Network Provider and we determine that the procedure was not medically necessary you will be responsible for the full charge.

Denied benefits that result from failure to follow notification requirements are not credited toward your out-of-pocket maximum. See What You Pay, page 3.

Notification Purpose Notification of most facility admissions and certain services helps us identify and initiate discharge planning or care coordination. Notification is required. Applies to For a complete list of the services subject to notification, visit Wellmark.com or call the Customer Service number on your ID card. Person Wellmark Blue POS Providers perform notification for you. However, you or Responsible someone acting on your behalf is responsible for notification if:

◼ You receive services subject to notification from a provider outside the Wellmark Blue POS network.

CHRXST 54 Form Number: Wellmark IA Grp/NR_ 0121 Notification Requirements and Care Coordination

Process When you, instead of your provider, are responsible for notification, call the phone number on your ID card before receiving services, except when you are unable to do so due to a medical emergency. In the case of an emergency admission, you must notify us within one business day of the admission or the receipt of services or as soon as reasonably possible thereafter.

Prior Approval Purpose Prior approval helps determine whether a proposed treatment plan is medically necessary and a benefit under your medical benefits. Prior approval is required. Applies to For a complete list of the services subject to prior approval, visit Wellmark.com or call the Customer Service number on your ID card. Person You or someone acting on your behalf is responsible for obtaining prior Responsible approval if: for Obtaining Prior Approval ◼ You receive services subject to prior approval from an Out-of-Network Provider; or ◼ You receive non-inpatient services subject to prior approval from a Participating Provider outside the Wellmark Blue POS network. Your Provider should obtain prior approval for you if:

◼ You receive services subject to prior approval from a Wellmark Blue POS Provider in Iowa; or ◼ You receive inpatient services subject to prior approval from a Participating Provider outside the Wellmark Blue POS network. Please note: If you are ever in doubt whether prior approval has been obtained, call the Customer Service number on your ID card. Process When you, instead of your provider, are responsible for requesting prior approval, call the number on your ID card to obtain a prior approval form and ask the provider to help you complete the form. Wellmark will determine whether the requested service is medically necessary and eligible for benefits based on the written information submitted to us. We will respond to a prior approval request in writing to you and your provider within:

◼ 72 hours in a medically urgent situation. ◼ 15 days in a non-medically urgent situation. Prior approval requests must include supporting clinical information to determine medical necessity of the services or supplies.

Form Number: Wellmark IA Grp/NR_ 0121 55 CHRXST Notification Requirements and Care Coordination

Importance If your request is approved, the service is covered provided other contractual requirements, such as member eligibility and benefits maximums, are observed. If your request is denied, the service is not covered, and you will receive a notice with the reasons for denial. If you do not request prior approval for a service, the benefit for that service will be denied on the basis that you did not request prior approval. Upon receiving an Explanation of Benefits (EOB) indicating a denial of benefits for failure to request prior approval, you will have the opportunity to appeal (see the Appeals section) and provide us with medical information for our consideration in determining whether the services were medically necessary and a benefit under your medical benefits. Upon review, if we determine the service was medically necessary and a benefit under your medical benefits, the benefit for that service will be provided according to the terms of your medical benefits. Approved services are eligible for benefits for a limited time. Approval is based on the medical benefits in effect and the information we had as of the approval date. If your coverage changes for any reason (for example, because of a new job or new medical benefits), an approval may not be valid. If your coverage changes before the approved service is performed, a new approval is recommended. Note: When prior approval is required, and an admission to a facility is required for that service, the admission also may be subject to notification or precertification. See Precertification and Notification earlier in this section.

Concurrent Review Purpose Concurrent review is a utilization review conducted during a member’s facility stay or course of treatment at home or in a facility setting to determine whether the place or level of service is medically necessary. This care coordination program occurs without any notification required from you. Applies to For a complete list of the services subject to concurrent review, visit Wellmark.com or call the Customer Service number on your ID card. Person Wellmark Responsible Process Wellmark may review your case to determine whether your current level of care is medically necessary. Responses to Wellmark's concurrent review requests must include supporting clinical information to determine medical necessity as a condition of your coverage. Importance Wellmark may require a change in the level or place of service in order to continue providing benefits. If we determine that your current facility setting or level of care is no longer medically necessary, we will notify you, your attending physician, and the facility or agency at least 24 hours before your benefits for these services end.

CHRXST 56 Form Number: Wellmark IA Grp/NR_ 0121 Notification Requirements and Care Coordination

Case Management Purpose Case management is intended to identify and assist members with the most severe illnesses or injuries by collaborating with members, members’ families, and providers to develop individualized care plans. Applies to A wide group of members including those who have experienced potentially preventable emergency room visits; hospital admissions/readmissions; those with catastrophic or high cost health care needs; those with potential long term illnesses; and those newly diagnosed with health conditions requiring lifetime management. Examples where case management might be appropriate include but are not limited to: Brain or Spinal Cord Injuries Cystic Fibrosis Degenerative Muscle Disorders Hemophilia Pregnancy (high risk) Transplants Person You, your physician, and the health care facility can work with Wellmark’s Responsible case managers. Wellmark may initiate a request for case management. Process Members are identified and referred to the Case Management program through Customer Service and claims information, referrals from providers or family members, and self-referrals from members. Importance Case management is intended to identify and coordinate appropriate care and care alternatives including reviewing medical necessity; negotiating care and services; identifying barriers to care including contract limitations and evaluation of solutions outside the group health plan; assisting the member and family to identify appropriate community-based resources or government programs; and assisting members in the transition of care when there is a change in coverage.

Prescription Drugs Prior Authorization of Drugs Purpose Prior authorization allows us to verify that a prescription drug is part of a specific treatment plan and is medically necessary. Applies to Consult the Drug List to determine if a particular drug requires prior authorization. You can locate this list by visiting Wellmark.com. You may also check with your pharmacist or practitioner to determine whether prior authorization applies to a drug that has been prescribed for you. Person You are responsible for prior authorization. Responsible

Form Number: Wellmark IA Grp/NR_ 0121 57 CHRXST Notification Requirements and Care Coordination

Process Ask your practitioner to call us with the necessary information. If your practitioner has not provided the prior authorization information, participating pharmacists usually ask for it, which may delay filling your prescription. To avoid delays, encourage your provider to complete the prior authorization process before filling your prescription. Wellmark will respond to a prior authorization request within:

◼ 72 hours in a medically urgent situation. ◼ 15 days in a non-medically urgent situation. Calls received after 4:00 p.m. are considered the next business day. Importance If you purchase a drug that requires prior authorization but do not obtain prior authorization, you are responsible for paying the entire amount charged.

CHRXST 58 Form Number: Wellmark IA Grp/NR_ 0121

7. Factors Affecting What You Pay

How much you pay for covered services is affected by many different factors discussed in this section.

Medical

◼ Benefits maximum. Benefit Year A benefit year is a period of 12 consecutive How Coinsurance is months beginning on January 1 or Calculated beginning on the day your coverage goes The amount on which coinsurance is into effect. The benefit year starts over each calculated depends on the state where you January 1. Your benefit year continues even receive a covered service and the if your employer or group sponsor changes contracting status of the provider. Wellmark group health plan benefits during the year or you change to a different plan Wellmark Blue POS and Out-of- offering mid-benefit year from your same Network Providers employer or group sponsor. Coinsurance is calculated using the payment arrangement amount after the following Certain coverage changes result in your amounts (if applicable) are subtracted from Wellmark identification number changing. it: In some cases, a new benefit year will start under the new ID number for the rest of the ◼ Deductible. benefit year. In this case, the benefit year ◼ Amounts representing any general would be less than a full 12 months. In other exclusions and conditions. See General cases (e.g., adding your spouse to your Conditions of Coverage, Exclusions, and coverage) the benefit year would continue Limitations, page 37. and not start over. Participating Providers Outside the If you are an inpatient in a covered facility Wellmark Blue POS Network on the date of your annual benefit year The coinsurance for covered services is renewal, your benefit limitations and calculated on the lower of: payment obligations, including your ◼ The amount charged for the covered deductible and out-of-pocket maximum, for service, or facility services will renew and will be based on the benefit limitations and payment ◼ The negotiated price that the Host Blue obligation amounts in effect on the date you makes available to Wellmark after the were admitted. However, your payment following amounts (if applicable) are obligations, including your deductible and subtracted from it: out-of-pocket maximum, for practitioner ⎯ Deductible. services will be based on the payment ⎯ Amounts representing any general obligation amounts in effect on the day you exclusions and conditions. See receive services. General Conditions of Coverage, Exclusions, and Limitations, page The benefit year is important for 37. calculating: Often, the negotiated price will be a simple ◼ Deductible. discount that reflects an actual price the ◼ Coinsurance. local Host Blue paid to your provider. ◼ Out-of-pocket maximum. Sometimes, the negotiated price is an

Form Number: Wellmark IA Grp/YP_ 0121 59 CHRXST Factors Affecting What You Pay estimated price that takes into account providers, including your designated special arrangements with your healthcare personal doctor. All other providers are not provider or provider group that may include in your network. types of settlements, incentive payments, and/or other credits or charges. Participating Providers Occasionally, the negotiated price may be an Participating Providers participate with a average price based on a discount that Blue Cross and/or Blue Shield Plan, but not results in expected average savings for with the Wellmark Blue POS network. When similar types of healthcare providers after you receive services from Participating taking into account the same types of Providers: transactions as with an estimated price. ◼ Level 2 Benefits apply if you have a Estimated pricing and average pricing, Wellmark-approved referral. going forward, also take into account adjustments to correct for over- or under- ◼ Level 3 Benefits apply if you do not have estimation of modifications of past pricing a Wellmark-approved referral. for the types of transaction modifications Wellmark Blue POS noted previously. However, such adjustments will not affect the price we use Providers for your claim because they will not be Wellmark has a contracting relationship applied retroactively to claims already paid. with these providers. When you receive services from a Wellmark Blue POS Occasionally, claims for services you receive Provider: from a provider that participates with a Blue Cross and/or Blue Shield Plan outside of ◼ Level 1 Benefits apply when you receive: Iowa or South Dakota may need to be ⎯ covered services from your processed by Wellmark instead of by the designated personal doctor. BlueCard Program. In that case, ⎯ covered chiropractic services from a coinsurance is calculated using the payment Wellmark Blue POS chiropractor. arrangement amount for covered services ⎯ covered occupational therapy after the following amounts (if applicable) services from a Wellmark Blue POS are subtracted from it: occupational therapist. ◼ Deductible. ⎯ covered physical therapy services ◼ Amounts representing any general from a Wellmark Blue POS physical exclusions and conditions. See General therapist. Conditions of Coverage, Exclusions, and ⎯ covered speech therapy services Limitations, page 37. from a Wellmark Blue POS speech Laws in a small number of states may pathologist. require the Host Blue Plan to add a ◼ Level 2 Benefits apply when you do not surcharge to your calculation. If any state receive covered services from your laws mandate other liability calculation designated personal doctor, excluding: methods, including a surcharge, Wellmark ⎯ covered chiropractic services from a will calculate your payment obligation for Wellmark Blue POS chiropractor. any covered services according to applicable ⎯ covered occupational therapy law. For more information, see BlueCard services from a Wellmark Blue POS Program, page 46. occupational therapist. Provider Network ⎯ covered physical therapy services from a Wellmark Blue POS physical Under the medical benefits of this plan, therapist. your network of providers consists of Wellmark Blue POS and Participating

CHRXST 60 Form Number: Wellmark IA Grp/YP_ 0121 Factors Affecting What You Pay

⎯ covered speech therapy services ◼ Wellmark does not make claim from a Wellmark Blue POS speech payments directly to these providers. pathologist. You are responsible for ensuring that ◼ The Wellmark Blue POS network your provider is paid in full. payment obligation amounts may be ◼ The group health plan payment for Out- waived or may be less than the Out-of- of-Network hospitals, M.D.s, and D.O.s Network amounts for certain covered in Iowa is made payable to the provider, services. See Waived Payment but the check is sent to you. You are Obligations, page 7. responsible for forwarding the check to the provider (plus any billed balance you Out-of-Network Providers may owe). Wellmark and Blue Cross and/or Blue Shield Plans do not have contracting Amount Charged and relationships with Out-of-Network Maximum Allowable Fee Providers, and they may not accept our payment arrangements. Pharmacies other Amount Charged than those participating in the specialty The amount charged is the amount a pharmacy program that do not contract with provider charges for a service or supply, our pharmacy benefits manager are regardless of whether the services or considered Out-of-Network Providers. supplies are covered under your medical Therefore, when you receive services from benefits. Out-of-Network Providers: Maximum Allowable Fee ◼ Level 3 Benefits apply. There may be The maximum allowable fee is the amount, exceptions to this rule for specific established by Wellmark, using various services. If so, these are described in the methodologies, for covered services and section Details – Services Covered and supplies. Wellmark’s amount paid may be Not Covered. based on the lesser of the amount charged ◼ You are responsible for any difference for a covered service or supply or the between the amount charged and our maximum allowable fee. payment for a covered service. In the case of services received outside Iowa or Payment Arrangements South Dakota, our maximum payment Payment Arrangement Savings for services by an Out-of-Network Wellmark has contracting relationships with Provider will generally be based on Wellmark Blue POS Providers. We use either the Host Blue’s Out-of-Network different methods to determine payment Provider local payment or the pricing arrangements, including negotiated fees. arrangements required by applicable These payment arrangements usually result state law. In certain situations, we may in savings. use other payment bases, such as the amount charged for a covered service, The savings from payment arrangements the payment we would make if the and other important amounts will appear on services had been obtained within Iowa your Explanation of Benefits statement as or South Dakota, or a special negotiated follows: payment, as permitted under Inter-Plan ◼ Network Savings, which reflects the Programs policies, to determine the amount you save on a claim by receiving amount we will pay for services you services from a Participating or receive from Out-of-Network Providers. Wellmark Blue POS provider. For the See Services Outside the Wellmark Blue majority of services, the savings reflects POS Network, page 46. the actual amount you save on a claim.

Form Number: Wellmark IA Grp/YP_ 0121 61 CHRXST Factors Affecting What You Pay

However, depending on many factors, per diems, percentage of charge, capitation, the amount we pay a provider could be or episodes of care. Some provider payment different from the covered charge. arrangements may include an amount Regardless of the amount we pay a payable to the provider based on the Participating or Wellmark Blue POS provider’s performance. Performance-based provider, your payment responsibility amounts that are not distributed are not will always be based on the lesser of the allocated to your specific group or to your covered charge or the maximum specific claims and are not considered when allowable fee. determining any amounts you may owe. We ◼ Amount Not Covered, which reflects the reserve the right to change the methodology portion of provider charges not covered we use to calculate payment arrangements under your health benefits and for which based on industry practice or business need. you are responsible. This amount may Wellmark Blue POS and Participating include services or supplies not covered; providers agree to accept our payment amounts in excess of a benefit arrangements as full settlement for maximum, benefit year maximum, or providing covered services, except to the lifetime benefits maximum; denials for extent of any amounts you may owe. failure to follow a required Capitation precertification; and the difference Payment to healthcare providers for certain between the amount charged and the services is made according to a uniform maximum allowable fee for services amount per patient as determined by from an Out-of-Network Provider. For Wellmark Health Plan of Iowa, Inc. general exclusions and examples of benefit limitations, see General Specialty Drug Manufacturer Conditions of Coverage, Exclusions, and Limitations, page 37. Discount Card Program Certain specialty medications may qualify ◼ Amount Paid by Health Plan, which reflects our payment responsibility to a for manufacturer discount card programs provider or to you. We determine this which could lower your out-of-pocket costs amount by subtracting the following for those products. You may not receive amounts (if applicable) from the amount credit toward your maximum out-of-pocket charged: for any deductible or coinsurance amounts that are applied to a manufacturer coupon ⎯ Deductible. or rebate. ⎯ Coinsurance. This Specialty Drug Manufacturer Discount ⎯ Copayment. Card Program is offered as part of your ⎯ Amounts representing any general plan’s exclusive specialty pharmacy network exclusions and conditions. with CVS Caremark’s affiliate CVS Specialty. ⎯ Network savings. The list of specialty drugs eligible for this Payment Method for Services Specialty Drug Manufacturer Discount Card When you receive a covered service or Program is subject to change as determined services that result in multiple claims, we by CVS Specialty. will calculate your payment obligations Drug Company Rebates based on the order in which we process the claims. Wellmark contracts with a pharmacy benefits manager to provide pharmacy Provider Payment Arrangements benefits management services. Drug Provider payment arrangements are manufacturers offer rebates to pharmacy calculated using industry methods benefits managers. Wellmark receives a including, but not limited to, fee schedules, share of these rebates from its pharmacy

CHRXST 62 Form Number: Wellmark IA Grp/YP_ 0121 Factors Affecting What You Pay benefits manager. Any rebates we receive specific claims and they will not be will be retained by us. The rebates will not considered when determining your payment be allocated to your specific group or to your obligations.

Prescription Drugs If a drug or pharmacy durable medical Benefit Year equipment device is not on the Drug List, it A benefit year is a period of 12 consecutive is not covered. months beginning on January 1 or If you need help determining if a particular beginning on the day your coverage goes drug or pharmacy durable medical into effect. The benefit year starts over each equipment device is on the Drug List, ask January 1. Your benefit year continues even your physician or pharmacist, visit our if your employer or group sponsor changes website, Wellmark.com, or call the Wellmark group health plan benefits during Customer Service number on your ID card. the year or you change to a different plan offering mid-benefit year from your same Although only drugs and pharmacy durable employer or group sponsor. medical equipment devices listed on the Drug List are covered, physicians are not Certain coverage changes result in your limited to prescribing only the drugs on the Wellmark identification number changing. list. Physicians may prescribe any In some cases, a new benefit year will start medication, but only medications on the under the new ID number for the rest of the Drug List are covered. Please note: A benefit year. In this case, the benefit year medication or pharmacy durable medical would be less than a full 12 months. In other equipment device on the Drug List will not cases (e.g., adding your spouse to your be covered if the drug or pharmacy durable coverage) the benefit year would continue medical equipment device is specifically and not start over. excluded under your Blue Rx Complete The benefit year is important for prescription drug benefits, or other calculating: limitations apply.

◼ Out-of-pocket maximum. If a drug or pharmacy durable medical equipment device is not on the Wellmark Wellmark Blue Rx Complete Blue Rx Complete Drug List and you believe Drug List it should be covered, refer to Exception Often there is more than one medication Requests for Non-Formulary Prescription available to treat the same medical Drugs, page 77. condition. The Wellmark Blue Rx Complete The Wellmark Blue Rx Complete Drug List Drug List (“Drug List”) contains drugs and is subject to change. pharmacy durable medical equipment devices physicians recognize as medically Tiers effective for a wide range of health The Wellmark Blue Rx Complete Drug List conditions. also identifies which tier a drug is on: The Drug List is maintained with the Tier 1. Most generic drugs and some brand- assistance of practicing physicians, name drugs that have no medically pharmacists, and Wellmark’s pharmacy appropriate generic equivalent. Tier 1 drugs department. have the lowest payment obligation. To determine if a drug or pharmacy durable Tier 2. Drugs appear on this tier because medical equipment device is covered, you or they either have no medically appropriate your physician must consult the Drug List. generic equivalent or are considered less

Form Number: Wellmark IA Grp/YP_ 0121 63 CHRXST Factors Affecting What You Pay cost-effective than Tier 1 drugs. Tier 2 drugs Rx Complete Drug List at Wellmark.com. have a higher payment obligation than Tier Also see Specialty Drugs, page 28. 1 drugs. Generic and Brand Name Tier 3. Drugs appear on this tier because they are less cost-effective than Tier 1 or Drugs Tier 2 drugs. Tier 3 drugs have a higher Generic Drug payment obligation than Tier 1 or Tier 2 Generic drug refers to an FDA-approved drugs. “A”-rated generic drug. This is a drug with Tier 4. Drugs available as combination active therapeutic ingredients chemically products, lifestyle drugs, or drugs with more identical to its brand name drug cost-effective options available on Tiers 1, 2, counterpart. or 3. Tier 4 drugs have the highest payment Brand Name Drug obligation. Brand name drug is a prescription drug Pharmacy DME. Devices available on this patented by the original manufacturer. tier include select durable medical Usually, after the patent expires, other equipment (DME) that are used in manufacturers may make FDA-approved conjunction with a drug and may be generic copies. obtained from a pharmacy. Sometimes, a patent holder of a brand name Preferred vs. Non-Preferred drug grants a license to another Specialty Drugs manufacturer to produce the drug under a generic name, though it remains subject to The Wellmark Blue Rx Complete Drug List patent protection and has a nearly identical also identifies which tier a specialty drug is price. In these cases, Wellmark’s pharmacy on: benefits manager may treat the licensed Preferred Specialty Drugs have been product as a brand name drug, rather than proven to be safe, effective, and favorably generic, and will calculate your payment priced compared to non-preferred obligation accordingly. alternatives that treat the same condition. What You Pay Drugs may also be classified as preferred In most cases, when you purchase a brand because no alternative drug exists. name drug that has an FDA-approved “A”- Non-Preferred Specialty Drugs are rated medically appropriate generic drugs without sufficiently documented equivalent, Wellmark will pay only what it clinical evidence establishing that they would have paid for the medically provide a significant benefit over available appropriate equivalent generic drug. You preferred alternatives. will be responsible for your payment The amount you pay for specialty drugs obligation for the medically appropriate covered under your Blue Rx Complete equivalent generic drug and any remaining prescription drug benefits depends on cost difference up to the maximum allowed whether a specialty drug is categorized as fee for the brand name drug. preferred or non-preferred. To determine Biologics and Biosimilars whether a specialty drug is preferred or non-preferred, consult the Wellmark Blue Biologics are specialty drugs made from natural and living sources and are usually more complex than other drugs. They are often more complicated to purify, process, and manufacture.

CHRXST 64 Form Number: Wellmark IA Grp/YP_ 0121 Factors Affecting What You Pay

Biosimilar Drug Quantity Limitations A biosimilar is a biologic drug. It is highly Most prescription drugs are limited to a similar to a biologic drug already approved maximum quantity you may receive in a by the FDA – the original biologic (also single prescription. called the reference product). Biosimilars also have no clinically meaningful Federal regulations limit the quantity that differences from the reference product. This may be dispensed for certain medications. If means you can expect the same safety and your prescription is so regulated, it may not effectiveness from the biosimilar over the be available in the amount prescribed by course of treatment as you would the your physician. reference product. Biosimilars are made In addition, coverage for certain drugs or from the same types of natural and living pharmacy durable medical equipment sources and are just as safe and effective as devices is limited to specific quantities per their reference products. month, benefit year, or lifetime. Amounts in Interchangeable Biosimilar Drug excess of quantity limitations are not Interchangeable biosimilar drug refers to an covered. FDA-approved biosimilar drug that meets For a list of drugs and pharmacy durable additional requirements based on further medical equipment devices with quantity evaluation and testing. This drug is expected limits, check with your pharmacist or to produce the same clinical result as the physician or consult the Wellmark Blue Rx reference product. Complete Drug List at Wellmark.com, or call the Customer Service number on your Reference Biologic Drug ID card. A reference product is the single brand biologic drug, already approved by the FDA, Amount Charged and against which a proposed biosimilar drug is Maximum Allowable Fee compared to and evaluated against to ensure that the product is highly similar and Amount Charged has no clinically meaningful differences. The retail price charged by a pharmacy for a covered prescription drug or pharmacy What You Pay durable medical equipment device. To determine what you would pay for a biologic or biosimilar specialty drug, consult Maximum Allowable Fee the Wellmark Blue Rx Complete Drug List The amount, established by Wellmark using at Wellmark.com. In most cases, when you various methodologies and data (such as the purchase a reference biologic drug that has average wholesale price), payable for an FDA-approved interchangeable covered drugs and pharmacy durable biosimilar, Wellmark will pay only what it medical equipment devices. would have paid for the medically appropriate equivalent interchangeable The maximum allowable fee may be less biosimilar drug. You will be responsible for than the amount charged for the drug or your payment obligation for the medically pharmacy durable medical equipment appropriate equivalent interchangeable device. biosimilar drug and any remaining cost Participating vs. difference up to the maximum allowed fee for the brand name reference biologic drug. Nonparticipating Pharmacies You must purchase prescription drugs from participating pharmacies (excluding specialty drugs, which must be purchased through the specialty pharmacy program.

Form Number: Wellmark IA Grp/YP_ 0121 65 CHRXST Factors Affecting What You Pay

See Specialty Drugs, page 28). Purchases The list of specialty drugs eligible for this from nonparticipating pharmacies are not Specialty Drug Manufacturer Discount Card covered. If you purchase drugs from Program is subject to change as determined nonparticipating pharmacies, you are by CVS Specialty. responsible for the cost of the drug. Savings and Rebates Your payment obligation for the purchase of a covered prescription drug at a Payment Arrangements participating pharmacy is the lesser of your The benefits manager of this prescription copayment or coinsurance, the maximum drug program has established payment allowable fee, or the amount charged for the arrangements with participating pharmacies drug. that may result in savings.

To determine if a pharmacy is participating, Drug Company Rebates ask the pharmacist, consult the directory of Wellmark contracts with a pharmacy participating pharmacies on our website at benefits manager to provide pharmacy Wellmark.com, or call the Customer Service benefits management services. Drug number on your ID card. Our directory also manufacturers offer rebates to pharmacy is available upon request by calling the benefits managers. Wellmark receives a Customer Service number on your ID card. share of these rebates from its pharmacy Special Programs benefits manager. Any rebates we receive will be retained by us. The rebates will not We evaluate and monitor changes in the be allocated to your specific group or to your pharmaceutical industry in order to specific claims and they will not be determine clinically effective and cost- considered when determining your payment effective coverage options. These obligations. evaluations may prompt us to offer programs that encourage the use of reasonable alternatives. For example, we may, at our discretion, temporarily waive your payment obligation on a qualifying prescription drug purchase. Visit our website at Wellmark.com or call us to determine whether your prescription qualifies. Specialty Drug Manufacturer Discount Card Program Certain specialty medications may qualify for manufacturer discount card programs which could lower your out-of-pocket costs for those products. You may not receive credit toward your maximum out-of-pocket for any coinsurance or copayment amounts that are applied to a manufacturer coupon or rebate. This Specialty Drug Manufacturer Discount Card Program is offered as part of your plan’s exclusive specialty pharmacy network with CVS Caremark’s affiliate CVS Specialty.

CHRXST 66 Form Number: Wellmark IA Grp/YP_ 0121

8. Coverage Eligibility and Effective Date

⎯ Medically necessary leaves of Eligible Members absence until the earlier of one year You are eligible for coverage if you meet from the first day of leave or the date your employer’s or group sponsor’s coverage would otherwise end. eligibility requirements. Your spouse may ◼ An unmarried child who is deemed also be eligible for coverage if spouses are disabled. The disability must have covered under this plan. existed before the child turned age 26 or If a child is eligible for coverage under the while the child was a full-time student. employer’s or group sponsor’s eligibility Wellmark considers a dependent requirements, the child must have one of disabled when he or she meets the the following relationships to the plan following criteria: member or an enrolled spouse: ⎯ Claimed as a dependent on the employee’s, plan member’s, ◼ A biological child. subscriber’s, policyholder’s, or ◼ Legally adopted or placed for adoption retiree’s tax return; and (that is, you assume a legal obligation to ⎯ Enrolled in and receiving Medicare provide full or partial support and benefits due to disability; or intend to adopt the child). ⎯ Enrolled in and receiving Social ◼ A child for whom you have legal Security benefits due to disability. guardianship. Documentation will be required. ◼ A stepchild. ◼ A foster child. Providing Social Security Numbers or Tax Identification Numbers ◼ A biological child a court orders to be covered. In order for Wellmark to report your coverage status to the federal government, A child who has been placed in your home you must provide to us your Social Security for the purpose of adoption or whom you number or tax identification number and have adopted is eligible for coverage on the the Social Security numbers or tax date of placement for adoption or the date identification numbers of all members of actual adoption, whichever occurs first. covered under your coverage and of any Please note: You must notify us or your member(s) added to your coverage. If you employer or group sponsor if you enter into have a newborn child while you are covered an arrangement to provide surrogate parent under your group health plan, you must services: Contact your employer or group notify us of the newborn’s social security sponsor or call the Customer Service number within six months of the child’s number on your ID card. birth. The IRS requires that Wellmark In addition, a child must be one of the report this information using the Social following: Security number or tax identification number of the plan member and each ◼ Under age 26. dependent. If Wellmark does not have ◼ An unmarried full-time student enrolled Social Security or tax identification in an accredited educational institution. numbers, we will be unable to report and Full-time student status continues send the information needed to complete during: federal tax returns. If you have not ⎯ Regularly-scheduled school previously provided your Social Security vacations; and number or tax identification number to

Form Number: Wellmark IA Grp/ELG_ 0121 67 CHRXST Coverage Eligibility and Effective Date

Wellmark for all members covered under Qualified Medical Child your coverage, you should contact us by Support Order calling the Customer Service number on If you have a dependent child and you or your ID card. If you do not provide the your spouse’s employer or group sponsor Social Security numbers or taxpayer receives a Medical Child Support Order identification numbers to Wellmark for this recognizing the child’s right to enroll in this purpose, you will be subject to a $50 penalty group health plan or in your spouse’s per violation imposed by the Internal benefits plan, the employer or group Revenue Service. sponsor will promptly notify you or your Please note: In addition to the preceding spouse and the dependent that the order has requirements, eligibility is affected by been received. The employer or group coverage enrollment events and coverage sponsor also will inform you or your spouse termination events. See Coverage Change and the dependent of its procedures for Events, page 71. determining whether the order is a Qualified Medical Child Support Order When Coverage Begins (QMCSO). Participants and beneficiaries Coverage begins on the member’s effective can obtain, without charge, a copy of such date. If you have just started a new job, or if procedures from the plan administrator. a coverage enrollment event allows you to A QMCSO specifies information such as: add a new member, ask your employer or group sponsor about your effective date. ◼ Your name and last known mailing Services received before the effective date of address. coverage are not eligible for benefits. ◼ The name and mailing address of the dependent specified in the court order. Late Enrollees ◼ A reasonable description of the type of A late enrollee is a member who declines coverage to be provided to the coverage when initially eligible to enroll and dependent or the manner in which the then later wishes to enroll for coverage. type of coverage will be determined. However, a member is not a late enrollee if a ◼ The period to which the order applies. qualifying enrollment event allows A Qualified Medical Child Support Order enrollment as a special enrollee, even if the cannot require that a benefits plan provide enrollment event coincides with a late any type or form of benefit or option not enrollment opportunity. See Coverage otherwise provided under the plan, except Change Events, page 71. as necessary to meet requirements of Iowa A late enrollee may enroll for coverage at Code Chapter 252E (2001) or Social the group’s next renewal or enrollment Security Act Section 1908 with respect to period. group health plans. Changes to Information The order and the notice given by the employer or group sponsor will provide Related to You or to Your additional information, including actions Benefits that you and the appropriate insurer must Wellmark may, from time to time, permit take to determine the dependent’s eligibility changes to information relating to you or to and procedures for enrollment in the your benefits. In such situations, Wellmark benefits plan, which must be done within shall not be required to reprocess claims as specified time limits. a result of any such changes. If eligible, the dependent will have the same coverage as you or your spouse and will be allowed to enroll immediately. You or your

CHRXST 68 Form Number: Wellmark IA Grp/ELG_ 0121 Coverage Eligibility and Effective Date spouse’s employer or group sponsor will withhold any applicable share of the cost of the dependent’s health care coverage from your compensation and forward this amount to us. If you are subject to a waiting period that expires more than 90 days after we receive the QMCSO, your employer or group sponsor must notify us when you become eligible for enrollment. Enrollment of the dependent will commence after you have satisfied the waiting period. The dependent may designate another person, such as a custodial parent or legal guardian, to receive copies of explanations of benefits, checks, and other materials. Your employer or group sponsor may not revoke enrollment or eliminate coverage for a dependent unless the employer or group sponsor receives satisfactory written evidence that:

◼ The court or administrative order requiring coverage in a group health plan is no longer in effect; ◼ The dependent’s eligibility for or enrollment in a comparable benefits plan that takes effect on or before the date the dependent’s enrollment in this group health plan terminates; or ◼ The employer eliminates dependent health coverage for all employees. The employer or group sponsor is not required to maintain the dependent’s coverage if:

◼ You or your spouse no longer pay the cost of coverage because the employer or group sponsor no longer owes compensation; or ◼ You or your spouse have terminated employment with the employer and have not elected to continue coverage.

Form Number: Wellmark IA Grp/ELG_ 0121 69 CHRXST

9. Coverage Changes and Termination

Certain events may require or allow you to ◼ Death. add or remove persons who are covered by ◼ Divorce or annulment (if spouses are this group health plan. eligible for coverage under this plan). Legal separation, also, may result in Coverage Change Events removal from coverage. If you become Coverage Enrollment Events: The legally separated, notify your employer following events allow you or your eligible or group sponsor. child to enroll for coverage. The following ◼ Medicare eligibility. If you become events may also allow your spouse to enroll eligible for Medicare, you must notify for coverage if spouses are eligible for your employer or group sponsor coverage under this plan. If your employer immediately. If you are eligible for this or group sponsor offers more than one group health plan other than as a group health plan, the event also allows you current employee or a current to move from one plan option to another. employee’s spouse (if spouses are ◼ Birth, adoption, or placement for eligible for coverage under this plan), adoption by an approved agency. your Medicare eligibility may terminate this coverage. ◼ Marriage. In case of the following coverage removal ◼ Exhaustion of COBRA coverage. events, the affected child’s coverage may be ◼ You or your eligible spouse or your continued until the end of the month on or dependent loses eligibility for creditable after the date of the event: coverage or his or her employer or group sponsor ceases contribution to ◼ Completion of full-time schooling if the creditable coverage. child is age 26 or older. ◼ Spouse (if eligible for coverage) loses ◼ Child who is not a full-time student or coverage through his or her employer. deemed disabled reaches age 26. ◼ You lose eligibility for coverage under ◼ Marriage of a child age 26 or older. Medicaid or the Children’s Health Insurance Program (CHIP) (the hawk-i Reinstatement of Child plan in Iowa). Reinstatement Events. A child up to age ◼ You become eligible for premium 26 who was removed from coverage may be assistance under Medicaid or CHIP. reinstated on his or her parent’s existing The following events allow you to add only coverage under any of the following the new dependent resulting from the event: conditions:

◼ Dependent child resumes status as a ◼ Involuntary loss of creditable coverage full-time student. (including, but not limited to, group or hawk-i coverage). ◼ Addition of a biological child by court order. See Qualified Medical Child ◼ Loss of creditable coverage due to: Support Order, page 68. ⎯ Termination of employment or ◼ Appointment as a child’s legal guardian. eligibility. ⎯ ◼ Placement of a foster child in your home Death of spouse. by an approved agency. ⎯ Divorce. Coverage Removal Events: The ◼ Court ordered coverage for spouse or following events require you to remove the minor children under the parent’s health affected family member from your coverage: insurance.

Form Number: Wellmark IA Grp/CC_ 0121 71 CHRXST Coverage Changes and Termination

◼ Exhaustion of COBRA or Iowa If you do not provide timely notification of continuation coverage. an event that requires you to remove an ◼ The plan member is employed by an affected family member, your coverage may employer that offers multiple health be terminated. plans and elects a different plan during If you do not provide timely notification of a an open enrollment period. coverage enrollment event, the affected ◼ A change in status in which the person may not enroll until an annual group employee becomes eligible to enroll in enrollment period. this group health plan and requests enrollment. See Coverage Enrollment Coverage Termination Events earlier in this section. The following events terminate your Reinstatement Requirements. A coverage eligibility. request for reinstated coverage for a child ◼ You become unemployed when your up to age 26 must be made within 31 days of eligibility is based on employment. the reinstatement event. In addition, the following requirements must be met: ◼ You become ineligible under your employer’s or group sponsor’s eligibility ◼ The child must have been covered under requirements for reasons other than the parent’s current coverage at the time unemployment. the child left that coverage to enroll in ◼ Your employer or group sponsor other creditable coverage. discontinues or replaces this group ◼ The parent’s coverage must be currently health plan. in effect and continuously in effect ◼ We decide to discontinue offering this during the time the child was enrolled in group health benefit plan by giving other creditable coverage. written notice to you and your employer Requirement to Notify Group or group sponsor and the Commissioner of Insurance at least 90 days prior to Sponsor termination. You must notify your employer or group ◼ We decide to nonrenew all group health sponsor of an event that changes the benefit plans delivered or issued for coverage status of members. Notify your delivery to employers in Iowa by giving employer or group sponsor within 60 days written notice to you and your employer in case of the following events: or group sponsor and the Commissioner ◼ A birth, adoption, or placement for of Insurance at least 180 days prior to adoption. termination. ◼ Divorce, legal separation, or annulment. ◼ The number of individuals covered under this group health plan falls below ◼ Your dependent child loses eligibility for coverage. the number or percentage of eligible individuals required to be covered. ◼ You lose eligibility for coverage under Medicaid or the Children’s Health ◼ Your employer sends a written request Insurance Program (CHIP) (the hawk-i to terminate coverage. plan in Iowa). Also see Fraud or Intentional Misrepresentation of Material Facts, and ◼ You become eligible for premium assistance under Medicaid or CHIP. Nonpayment later in this section. For all other events, you must notify your When you become unemployed and your employer or group sponsor within 60 days eligibility is based on employment, your of the event. coverage will end at the end of the month your employment ends. When your coverage terminates for all other reasons,

CHRXST 72 Form Number: Wellmark IA Grp/CC_ 0121 Coverage Changes and Termination check with your employer or group sponsor Nonpayment or call the Customer Service number on If you or your employer or group sponsor your ID card to verify the coverage fail to make required payments to us when termination date. due or within the allowed grace period, your coverage will terminate the last day of the If you receive covered facility services as an month in which the required payments are inpatient of a hospital or a resident of a due. nursing facility on the date your coverage eligibility terminates, payment for the Coverage Continuation covered facility services will end on the When your coverage ends, you may be earliest of the following: eligible to continue coverage under this ◼ The end of your remaining days of group health plan. coverage under this benefits plan. COBRA Continuation ◼ The date you are discharged from the hospital or nursing facility following The federal Consolidated Omnibus Budget termination of your coverage eligibility. Reconciliation Act (COBRA) applies to most non-governmental employers with 20 or ◼ A period not more than 60 days from more employees. Generally, COBRA entitles the date of termination. you and eligible dependents to continue Only facility services will be covered under coverage if it is lost due to a qualifying this extension of benefits provision. Benefits event, such as employment termination, for professional services will end on the date divorce, or loss of dependent status. You of termination of your coverage eligibility. and your eligible dependents will be Fraud or Intentional required to pay for continuation coverage. Misrepresentation of Material Facts Other federal or state laws similar to Your coverage will terminate immediately if: COBRA may apply if COBRA does not. Your employer or group sponsor is required to ◼ You use this group health plan provide you with additional information on fraudulently or intentionally continuation coverage if a qualifying event misrepresent a material fact in your occurs. application; or ◼ Your employer or group sponsor Continuation Under Iowa Law commits fraud or intentionally Under Iowa Code Chapter 509B, you may be misrepresents a material fact under the eligible to continue your medical care terms of this group health plan. coverage for up to nine months if: If your coverage is terminated for fraud or ◼ You lose the coverage you have been intentional misrepresentation of a material receiving through your employer or fact, then: group sponsor; and

◼ We may declare this group health plan ◼ You have been covered by your medical void retroactively from the effective date benefits plan continuously for the last of coverage following a 30-day written three months. notice. In this case, we will recover any Your employer or group sponsor must claim payments made, minus any provide written notice of your right to premiums paid. continue coverage within 10 days of the last ◼ Premiums may be retroactively adjusted day you are considered employed or your as if the fraud or intentionally coverage ends. You will then have 10 days to misrepresented material fact had been give your employer or group sponsor accurately disclosed in your application. written notice that you want to continue coverage. ◼ We will retain legal rights, including the right to bring a civil action.

Form Number: Wellmark IA Grp/CC_ 0121 73 CHRXST Coverage Changes and Termination

Your right to continue coverage ends 31 days after the date of your employment termination or the date you were given notice of your continuation right, whichever is later. If you lose your coverage because of divorce, annulment, or death of the employee, you must notify the employer or group sponsor providing the coverage within 31 days. Benefits provided by continuation coverage may not be identical to the benefits that active employees have and will be subject to different premium rates. You will be responsible for paying any premiums to your employer or group sponsor for continuation coverage. If you believe the Iowa continuation law applies to you, you may contact your employer or group sponsor for information on premiums and any necessary paperwork. If you are eligible for coverage continuation under both Iowa law and COBRA, your employer can comply with Iowa law by offering only COBRA continuation.

CHRXST 74 Form Number: Wellmark IA Grp/CC_ 0121

10. Claims

Once you receive services, we must receive a How to File a Claim claim to determine the amount of your benefits. The claim lets us know the services All claims must be submitted in writing. you received, when you received them, and 1. Get a Claim Form from which provider. Forms are available at Wellmark.com or by Neither you nor your provider shall bill calling the Customer Service number on Wellmark for services provided under a your ID card or from your personnel direct primary care agreement as authorized department. under Iowa law. 2. Fill Out the Claim Form When to File a Claim Follow the same claim filing procedure regardless of where you received services. You need to file a claim if you: Directions are printed on the back of the ◼ Use a provider who does not file claims claim form. Complete all sections of the for you. Participating and Wellmark claim form. For more efficient processing, Blue POS providers file claims for you. all claims (including those completed out- ◼ Purchase prescription drugs from a of-country) should be written in English. participating pharmacy but do not If you need assistance completing the claim present your ID card. form, call the Customer Service number on ◼ Pay in full for a drug that you believe your ID card. should have been covered. Medical Claim Form. Follow these steps Your submission of a prescription to a to complete a medical claim form: participating pharmacy is not a filed claim and therefore is not subject to appeal ◼ Use a separate claim form for each procedures as described in the Appeals covered family member and each section. However, you may file a claim with provider. us for a prescription drug purchase you ◼ Attach a copy of an itemized statement think should have been a covered benefit. prepared by your provider. We cannot accept statements you prepare, cash Wellmark must receive claims within 180 register receipts, receipt of payment days following the date of service of the notices, or balance due notices. In order claim or if you have other coverage that has for a claim request to qualify for primary responsibility for payment then processing, the itemized statement must within 180 days of the date of the other be on the provider’s stationery, and carrier's explanation of benefits. If you include at least the following: receive services outside of Wellmark’s service area, Wellmark must receive the ⎯ Identification of provider: full name, claim within 180 days following the date of address, tax or license ID numbers, service or within the filing requirement in and provider numbers. the contractual agreement between the ⎯ Patient information: first and last Participating Provider and the Host Blue. If name, date of birth, gender, you receive services from an Out-of- relationship to plan member, and Network Provider, the claim has to be filed daytime phone number. within 180 days following the date of ⎯ Date(s) of service. service. ⎯ Charge for each service. ⎯ Place of service (office, hospital, etc.).

Form Number: Wellmark IA Grp/CL_ 0121 75 CHRXST Claims

⎯ For injury or illness: date and 3. Sign the Claim Form diagnosis. 4. Submit the Claim ⎯ For inpatient claims: admission We recommend you retain a copy for your date, patient status, attending records. The original form you send or any physician ID. attachments sent with the form cannot be ⎯ Days or units of service. returned to you. ⎯ Revenue, diagnosis, and procedure Medical Claims and Claims for Drugs codes. Covered Under Your Medical ⎯ Description of each service. Benefits. Send the claim to: Prescription Drugs Covered Under Your Medical Benefits Claim Form. Wellmark For prescription drugs covered under your Station 1E238 medical benefits (not covered under your P.O. Box 9291 Blue Rx Complete prescription drug Des Moines, IA 50306-9291 benefits), use a separate prescription drug Medical Claims for Services Received claim form and include the following Outside the United States. Send the information: claim to the address printed on the claim ◼ Pharmacy name and address. form. ◼ Patient information: first and last name, Blue Rx Complete Prescription Drug date of birth, gender, and relationship to Claims. Send the claim to the address plan member. printed on the claim form. ◼ Date(s) of service. We may require additional information ◼ Description and quantity of drug. from you or your provider before a claim ◼ Original pharmacy receipt or cash can be considered complete and ready for receipt with the pharmacist’s signature processing. on it. Blue Rx Complete Prescription Drug Notification of Decision Claim Form. For prescription drugs You will receive an Explanation of Benefits covered under your Blue Rx Complete (EOB) following your claim. The EOB is a prescription drug benefits, complete the statement outlining how we applied benefits following steps: to a submitted claim. It details amounts that providers charged, network savings, our ◼ Use a separate claim form for each paid amounts, and amounts for which you covered family member and each are responsible. pharmacy. ◼ Complete all sections of the claim form. In case of an adverse decision, the notice Include your daytime telephone will be sent within 30 days of receipt of the number. claim. We may extend this time by up to 15 days if the claim determination is delayed ◼ Submit up to three prescriptions for the same family member and the same for reasons beyond our control. If we do not pharmacy on a single claim form. Use send an explanation of benefits statement or additional claim forms for claims that a notice of extension within the 30-day exceed three prescriptions or if the period, you have the right to begin an prescriptions are for more than one appeal. We will notify you of the family member or pharmacy. circumstances requiring an extension and the date by which we expect to render a ◼ Attach receipts to the back of the claim decision. form in the space provided.

CHRXST 76 Form Number: Wellmark IA Grp/CL_ 0121 Claims

If an extension is necessary because we ◼ All covered formulary drugs on any tier require additional information from you, would not be as effective as the non- the notice will describe the specific formulary drug; or information needed. You have 45 days from ◼ All covered formulary drugs would have receipt of the notice to provide the adverse effects. information. Without complete information, Wellmark will respond within 72 hours of your claim will be denied. receiving the Exception Request for Non- If you have other insurance coverage, our Formulary Prescription Drugs form. For processing of your claim may utilize expedited requests, Wellmark will respond coordination of benefits guidelines. See within 24 hours. Coordination of Benefits, page 79. In the event Wellmark denies your Once we pay your claim, whether our exception request, you and your provider payment is sent to you or to your provider, will be sent additional information our obligation to pay benefits for the claim regarding your ability to request an is discharged. However, we may adjust a independent review of our decision. If the claim due to overpayment or independent reviewer approves your underpayment. In the case of Out-of- exception request, we will treat the drug as a Network hospitals, M.D.s, and D.O.s located covered benefit for the duration of your in Iowa, the health plan payment is made prescription. You will be responsible for payable to the provider, but the check is out-of-pocket costs (for example: sent to you. You are responsible for deductible, copay, or coinsurance, if forwarding the check to the provider, plus applicable) as if the non-formulary drug is any difference between the amount charged on the highest tier of the Wellmark Blue Rx and our payment. Complete Drug List. Amounts you pay will be counted toward any applicable out-of- Exception Requests for Non- pocket maximums. If the independent Formulary Prescription reviewer upholds Wellmark’s denial of your Drugs exception request, the drug will not be covered, and this decision will not be Prescription drugs that are not listed on the considered an adverse benefit Wellmark Blue Rx Complete Drug List are determination, and will not be eligible for not covered. However, you may submit an further appeals. You may choose to exception request for coverage of a non- purchase the drug at your own expense. formulary drug (i.e., a drug that is not included on the Wellmark Blue Rx Complete The Exception Request for Non-Formulary Drug List). The form is available at Prescription Drugs process is only available Wellmark.com or by calling the Customer for FDA-approved prescription drugs that Service number on your ID card. Your are not on the Wellmark Blue Rx Complete prescribing physician or other provider Drug List. It is not available for items that must provide a clinical justification are specifically excluded under your supporting the need for the non-formulary benefits, such as cosmetic drugs, drug to treat your condition. The provider convenience packaging, non-FDA approved should include a statement that: drugs, drugs not approved to be covered by Wellmark’s P&T Committee, infused drugs, ◼ All covered formulary drugs on any tier most over-the-counter medications, have been ineffective; or nutritional, vitamin and dietary ◼ All covered formulary drugs on any tier supplements, or antigen therapy. The will be ineffective; or preceding list of excluded items is illustrative only and is not a complete list of items that are not eligible for the process.

Form Number: Wellmark IA Grp/CL_ 0121 77 CHRXST Claims

Request for Benefit Exception ◼ Certain immunizations that ACIP Review recommends for specified individuals (rather than for routine use for an entire If you have received an adverse benefit population), when prescribed by your determination that denies or reduces health care provider consistent with the benefits or fails to provide payment in whole ACIP recommendations. or in part for any of the following services, when recommended by your treating ◼ FDA-approved intrauterine devices and provider as medically necessary, you or an implants, if prescribed by your health individual acting as your authorized care provider. representative may request a benefit ◼ Brand name drug when the generic exception review. equivalent drug is available, if your provider determines the brand name Services subject to this exception process: drug is medically necessary and the ◼ For a woman who previously has had generic equivalent drug is medically breast cancer, ovarian cancer, or other inappropriate. cancer, but who has not been diagnosed You may request a benefit exception review with BRCA-related cancer, appropriate orally or in writing by submitting your preventive screening, genetic request to the address listed in the Appeals counseling, and genetic testing. section. To be considered, your request ◼ FDA-approved contraceptive items or must include supporting medical record services prescribed by your health care documentation and a letter or statement provider based upon a specific from your treating provider that the services determination of medical necessity for or supplies were medically necessary and you. your treating provider’s reason(s) for their ◼ For transgender individuals, sex-specific determination that the services or supplies preventive care services (e.g., were medically necessary. mammograms and Pap smears) that his Your request will be addressed within the or her attending provider has timeframes outlined in the Appeals section determined are medically appropriate. based upon whether your request is a ◼ For dependent children, certain well- medically urgent or non-medically urgent woman preventive care services that the matter. attending provider determined are age- and developmentally-appropriate. ◼ Anesthesia services in connection with a preventive colonoscopy when your attending provider determined that anesthesia would be medically appropriate. ◼ A required consultation prior to a screening colonoscopy, if your attending provider determined that the pre- procedure consultation would be medically appropriate for you. ◼ If you received pathology services from an in-network provider related to a preventive colonoscopy screening for which you were responsible for a portion of the cost, such as a deductible, copayment or coinsurance.

CHRXST 78 Form Number: Wellmark IA Grp/CL_ 0121

11. Coordination of Benefits

Coordination of benefits applies when you ◼ Medicare or other governmental have more than one plan, insurance policy, benefits (not including Medicaid). or group health plan that provides the same ◼ The medical benefits coverage of your or similar benefits as this plan. Benefits auto insurance (whether issued on a payable under this plan, when combined fault or no-fault basis). with those paid under your other coverage, Coverage that is not subject to coordination will not be more than 100 percent of either of benefits includes the following: our payment arrangement amount or the other plan’s payment arrangement amount. ◼ Hospital indemnity coverage or other fixed indemnity coverage. The method we use to calculate the payment ◼ Accident-only coverage. arrangement amount may be different from ◼ Specified disease or specified accident your other plan’s method. coverage. In some instances, our claim payment ◼ Limited benefit health coverage, as amount is based on a uniform payment per defined by Iowa law. patient of a designated personal doctor, ◼ School accident-type coverage. called capitation. When you receive services ◼ Benefits for nonmedical components of payable by capitation and your other carrier long-term care policies. has primary payment responsibility for covered services: ◼ Medicare supplement policies. ◼ Medicaid policies. ◼ We are not responsible for payment to ◼ Coverage under other governmental your health care provider beyond the plans, unless permitted by law. applicable capitation amount; and You must cooperate with Wellmark and ◼ You are not responsible for copayment provide requested information about other amounts that would apply if coverage coverage. Failure to provide information can under this medical benefits plan were the primary coverage. result in a denied claim. We may get the facts we need from or give them to other Other Coverage organizations or persons for the purpose of applying the following rules and When you receive services, you must inform determining the benefits payable under this us that you have other coverage, and inform plan and other plans covering you. We need your health care provider about your other not tell, or get the consent of, any person to coverage. Other coverage includes any of the do this. following: Your Wellmark Blue POS Provider will ◼ Group and nongroup insurance forward your coverage information to us. If contracts and subscriber contracts. you see an Out-of-Network Provider, you ◼ HMO contracts. are responsible for informing us about your ◼ Uninsured arrangements of group or other coverage. group-type coverage. ◼ Group and nongroup coverage through Claim Filing closed panel plans. If you know that your other coverage has ◼ Group-type contracts. primary responsibility for payment, after ◼ The medical care components of long- you receive services or obtain a covered term contracts, such as skilled nursing prescription drug, a claim should be care. submitted to your other insurance carrier

Form Number: Wellmark IA Grp/COB_ 0121 79 CHRXST Coordination of Benefits first. If that claim is processed with an federal law, Medicare is secondary to the unpaid balance for benefits eligible under plan covering the person as a dependent this group health plan, you or your provider and primary to the plan covering the should submit a claim to us and attach the person as other than a dependent (e.g., a other carrier’s explanation of benefit retired employee), then the order of payment within 180 days of the date of the benefits between the two plans is other carrier's explanation of benefits. We reversed, so that the plan covering the may contact your provider or the other person as the employee, plan member, carrier for further information. subscriber, policyholder or retiree is the secondary plan and the other plan is the Rules of Coordination primary plan. We follow certain rules to determine which ◼ The coverage that you have as the result health plan or coverage pays first (as the of active employment (not laid off or primary plan) when other coverage provides retired) pays before coverage that you the same or similar benefits as this group have as a laid-off or retired employee. health plan. Here are some of those rules: The same would be true if a person is a dependent of an active employee and ◼ The primary plan pays or provides benefits according to its terms of that same person is a dependent of a coverage and without regard to the retired or laid-off employee. If the other benefits under any other plan. Except as plan does not have this rule and, as a provided below, a plan that does not result, the plans do not agree on the contain a coordination of benefits order of benefits, this rule is ignored. provision that is consistent with ◼ If a person whose coverage is provided applicable regulations is always primary pursuant to COBRA or under a right of unless the provisions of both plans state continuation provided by state or other that the complying plan is primary. federal law is covered under another plan, the plan covering the person as an ◼ Coverage that is obtained by membership in a group and is designed employee, plan member, subscriber, to supplement a part of a basic package policyholder or retiree or covering the of benefits is excess to any other parts of person as a dependent of an employee, the plan provided by the contract member, subscriber or retiree is the holder. (Examples of such primary plan and the COBRA or state or supplementary coverage are major other federal continuation coverage is medical coverage that is superimposed the secondary plan. If the other plan over base plan hospital and surgical does not have this rule and, as a result, benefits and insurance-type coverage the plans do not agree on the order of written in connection with a closed benefits, this rule is ignored. panel plan to provide Out-of-Network ◼ The coverage with the earliest benefits.) continuous effective date pays first if The following rules are to be applied in none of the rules above apply. order. The first rule that applies to your ◼ Notwithstanding the preceding rules, situation is used to determine the primary when you present your Blue Rx plan. Complete ID card to a pharmacy as the primary payer, your Blue Rx Complete ◼ The coverage that you have as an prescription drug benefits are primary employee, plan member, subscriber, for prescription drugs purchased at the policyholder, or retiree pays before pharmacy. If, under the preceding rules, coverage that you have as a spouse or your Blue Rx Complete prescription dependent. However, if the person is a drug benefits are secondary and you Medicare beneficiary and, as a result of present your Blue Rx Complete ID card

CHRXST 80 Form Number: Wellmark IA Grp/COB_ 0121 Coordination of Benefits

to a pharmacy as the secondary payer, knowledge of the court decree your Blue Rx Complete prescription provision. drug benefits are secondary for ⎯ If a court decree states that both prescription drugs purchased at the parents are responsible for the pharmacy. child’s health care expense or health ◼ If the preceding rules do not determine care coverage or if a court decree the order of benefits and if the plans states that the parents have joint cannot agree on the order of benefits custody without specifying that one within 30 calendar days after the plans parent has responsibility for the have received all information needed to health care expenses or coverage of pay the claim, the plans will pay the the dependent child, then the claim in equal shares and determine coverage of the parent whose their relative liabilities following birthday occurs first in a calendar payment. However, we will not pay more year pays first. If both parents have than we would have paid had this plan the same birthday, the plan that has been primary. covered the parent the longest is the primary plan. Dependent Children ⎯ If a court decree does not specify To coordinate benefits for a dependent which parent has financial or child, the following rules apply (unless there insurance responsibility, then the is a court decree stating otherwise): coverage of the parent with custody ◼ If the child is covered by both parents pays first. The payment order for the who are married (and not separated) or child is as follows: custodial parent, who are living together, whether or not spouse of custodial parent, other they have been married, then the parent, spouse of other parent. A coverage of the parent whose birthday custodial parent is the parent occurs first in a calendar year pays first. awarded custody by a court decree If both parents have the same birthday, or, in the absence of a court decree, the plan that has covered the parent the is the parent with whom the child longest is the primary plan. resides more than one-half of the ◼ For a child covered by separated or calendar year excluding any divorced parents or parents who are not temporary visitation. living together, whether or not they have ◼ For a dependent child covered under been married: more than one plan of individuals who ⎯ If a court decree states that one of are not the parents of the child, the the parents is responsible for the order of benefits shall be determined, as child’s health care expenses or applicable, as outlined previously in this coverage and the plan of that parent Dependent Children section. has actual knowledge of those terms, ◼ For a dependent child who has coverage then that parent’s coverage pays under either or both parents’ plans and first. If the parent with responsibility also has his or her own coverage as a has no health care coverage for the dependent under a spouse’s plan, the dependent child’s health care plan that covered the dependent for the expenses, but that parent’s spouse longer period of time is the primary does, that parent’s spouse’s coverage plan. If the dependent child’s coverage pays first. This item does not apply under the spouse’s plan began on the with respect to any plan year during same date as the dependent child’s which benefits are paid or provided coverage under either or both parents’ before the entity has actual plans, the order of benefits shall be determined, as applicable, as outlined in

Form Number: Wellmark IA Grp/COB_ 0121 81 CHRXST Coordination of Benefits

the first bullet of this Dependent advance, we will be subrogated to all of Children section, to the dependent your rights against the noncomplying child’s parent or parents and the plan. See Subrogation, page 98. dependent’s spouse. ◼ If the preceding rules do not determine ◼ If the preceding rules do not determine the order of benefits and if the plans the order of benefits and if the plans cannot agree on the order of benefits cannot agree on the order of benefits within 30 calendar days after the plans within 30 calendar days after the plans have received all information needed to have received all information needed to pay the claim, the plans will pay the pay the claim, the plans will pay the claim in equal shares and determine claim in equal shares and determine their relative liabilities following their relative liabilities following payment. However, we will not pay more payment. However, we will not pay more than we would have paid had this plan than we would have paid had this plan been primary. been primary. Effects on the Benefits of this Plan Coordination with Noncomplying In determining the amount to be paid for Plans any claim, the secondary plan will calculate If you have coverage with another plan that the benefits it would have paid in the is excess or always secondary or that does absence of other coverage and apply the not comply with the preceding rules of calculated amount to any allowable expense coordination, we may coordinate benefits on under its plan that is unpaid by the primary the following basis: plan. The secondary plan may then reduce its payment by the amount so that, when ◼ If this is the primary plan, we will pay its benefits first. combined with the amount paid by the primary plan, total benefits paid or provided ◼ If this is the secondary plan, we will pay by all plans for the claim do not exceed the benefits first, but the amount of benefits total allowable expense for that claim. In will be determined as if this plan were addition, the secondary plan will credit to its secondary. Our payment will be limited applicable deductible any amounts it would to the amount we would have paid had have credited to its deductible in the this plan been primary. absence of other coverage. ◼ If the noncomplying plan does not provide information needed to If a person is enrolled in two or more closed determine benefits, we will assume that panel plans and if, for any reason including the benefits of the noncomplying plan the provision of service by a non-panel are identical to this plan and will provider, benefits are not payable by one administer benefits accordingly. If we closed panel plan, coordination of benefits receive the necessary information within will not apply between that plan and other two years of payment of the claim, we closed panel plans. will adjust payments accordingly. Right of Recovery ◼ In the event that the noncomplying plan If the amount of payments made by us is reduces its benefits so you receive less more than we should have paid under these than you would have received if we had coordination of benefits provisions, we may paid as the secondary plan and the recover the excess from any of the persons noncomplying plan was primary, we will to or for whom we paid, or from any other advance an amount equal to the person or organization that may be difference. In no event will we advance responsible for the benefits or services more than we would have paid had this provided for the covered person. The plan been primary, minus any amount amount of payments made includes the previously paid. In consideration of the

CHRXST 82 Form Number: Wellmark IA Grp/COB_ 0121 Coordination of Benefits

reasonable cash value of any benefits ◼ A recipient of Medicare disability provided in the form of services. benefits; and ◼ A current employee or a spouse or Plans That Provide Benefits as dependent of a current employee, Services covered by an employer group health A secondary plan that provides benefits in plan. the form of services may recover the reasonable cash value of the service from End-Stage Renal Disease (ESRD) the primary plan, to the extent benefits for The ESRD requirements apply to group the services are covered by the primary plan health plans of all employers, regardless of and have not already been paid or provided the number of employees. Under these by the primary plan. requirements, Medicare is the secondary payer during the first 30 months of Coordination with Medicare Medicare eligibility if both of the following Medicare is by law the secondary coverage are true: to group health plans in a variety of ◼ The beneficiary is eligible for Medicare situations. coverage as an ESRD patient; and The following provisions apply only if you ◼ The beneficiary is covered by an have both Medicare and employer group employer group health plan. health coverage and meet the specific If the beneficiary is already covered by Medicare Secondary Payer provisions for Medicare due to age or disability and the the applicable Medicare entitlement reason. beneficiary becomes eligible for Medicare Medicare Part B Drugs ESRD coverage, Medicare generally is the Drugs paid under Medicare Part B are secondary payer during the first 30 months covered under the medical benefits of this of ESRD eligibility. However, if the group plan. health plan is secondary to Medicare (based on other Medicare secondary-payer Working Aged requirements) at the time the beneficiary If you are a member of a group health plan becomes eligible for ESRD, the group health of an employer with at least 20 employees plan remains secondary to Medicare. for each working day for at least 20 calendar This is only a general summary of the laws. weeks in the current or preceding year, then For complete information, contact your in most situations Medicare is the secondary employer or the Social Security payer if the beneficiary is: Administration. ◼ Age 65 or older; and ◼ A current employee or spouse of a current employee covered by an employer group health plan.

Working Disabled If you are a member of a group health plan of an employer with at least 100 full-time, part-time, or leased employees on at least 50 percent of regular business days during the preceding calendar year, then in most situations Medicare is the secondary payer if the beneficiary is:

◼ Under age 65;

Form Number: Wellmark IA Grp/COB_ 0121 83 CHRXST

12. Appeals

Right of Appeal You have the right to one full and fair review What to Include in Your Internal in the case of an adverse benefit Appeal determination that denies, reduces, or You must submit all relevant information terminates benefits, or fails to provide with your appeal, including the reason for payment in whole or in part. Adverse benefit your appeal. This includes written determinations include a denied or reduced comments, documents, or other information claim, a rescission of coverage, or an in support of your appeal. You must also adverse benefit determination concerning a submit: pre-service notification requirement. Pre- ◼ Date of your request. service notification requirements are: ◼ Your name (please type or print), ◼ A precertification request. address, and if applicable, the name and ◼ A notification of admission or services. address of your authorized ◼ A prior approval request. representative. ◼ A prior authorization request for ◼ Member identification number. prescription drugs. ◼ Claim number from your Explanation of Benefits, if applicable. How to Request an Internal ◼ Date of service in question. Appeal For a prescription drug appeal, you You or your authorized representative, if also must submit: you have designated one, may appeal an adverse benefit determination within 180 ◼ Name and phone number of the days from the date you are notified of our pharmacy. adverse benefit determination by ◼ Name and phone number of the submitting a written appeal. Appeal forms practitioner who wrote the prescription. are available at our website, Wellmark.com. ◼ A copy of the prescription. See Authorized Representative, page 95. ◼ A brief description of your medical reason for needing the prescription. Medically Urgent Appeal If you have difficulty obtaining this To appeal an adverse benefit determination information, ask your provider or involving a medically urgent situation, you pharmacist to assist you. may request an expedited appeal, either orally or in writing. Medically urgent Where to Send Internal generally means a situation in which your health may be in serious jeopardy or, in the Appeal opinion of your physician, you may Wellmark Health Plan of Iowa, Inc. experience severe pain that cannot be Special Inquiries adequately controlled while you wait for a P.O. Box 9232, Station 5W189 decision. Des Moines, IA 50306-9232 Non-Medically Urgent Appeal Review of Internal Appeal To appeal an adverse benefit determination Your request for an internal appeal will be that is not medically urgent, you must make reviewed only once. The review will take your request for a review in writing. into account all information regarding the adverse benefit determination whether or not the information was presented or

Form Number: Wellmark IA Grp/AP_ 0121 85 CHRXST Appeals available at the initial determination. Upon involving a covered service when the request, and free of charge, you will be determination involved: provided reasonable access to and copies of ◼ Medical necessity. all relevant records used in making the ◼ Appropriateness of services or supplies, initial determination. Any new information including health care setting, level of or rationale gathered or relied upon during care, or effectiveness of treatment. the appeal process will be provided to you prior to Wellmark issuing a final adverse ◼ Investigational or experimental services benefit determination and you will have the or supplies. opportunity to respond to that information ◼ Concurrent review or admission to a or to provide information. facility. See Notification Requirements and Care Coordination, page 53. The review will not be conducted by the ◼ A rescission of coverage. original decision makers or any of their subordinates. The review will be conducted An adverse determination eligible for without regard to the original decision. If a external review does not include a denial of decision requires medical judgment, we will coverage for a service or treatment consult an appropriate medical expert who specifically excluded under this plan. was not previously involved in the original The external review will be conducted by decision and who has no conflict of interest independent health care professionals who in making the decision. If we deny your have no association with us and who have appeal, in whole or in part, you may request, no conflict of interest with respect to the in writing, the identity of the medical expert benefit determination. we consulted. Have you exhausted the appeal Decision on Internal Appeal process? Before you can request an external review, you must first exhaust the The decision on appeal is the final internal internal appeal process described earlier in determination. Once a decision on internal this section. However, if you have not appeal is reached, your right to internal received a decision regarding the adverse appeal is exhausted. benefit determination within 30 days Medically Urgent Appeal following the date of your request for an For a medically urgent appeal, you will be appeal, you are considered to have notified (by telephone, e-mail, fax or exhausted the internal appeal process. another prompt method) of our decision as Requesting an external review. You or soon as possible, based on the medical your authorized representative may request situation, but no later than 72 hours after an external review through the Iowa your expedited appeal request is received. If Insurance Division by completing an the decision is adverse, a written External Review Request Form and notification will be sent. submitting the form as described in this All Other Appeals section. You may obtain this request form For all other appeals, you will be notified in by calling the Customer Service number on writing of our decision. Most appeal your ID card, by visiting our website at requests will be determined within 30 days Wellmark.com, by contacting the Iowa and all appeal requests will be determined Insurance Division, or by visiting the Iowa within 60 days. Insurance Division's website at www.iid.iowa.gov. External Review You will be required to authorize the release You have the right to request an external of any medical records that may be required review of a final adverse determination

CHRXST 86 Form Number: Wellmark IA Grp/AP_ 0121 Appeals to be reviewed for the purpose of reaching a determination that concerns an admission, decision on your request for external review. availability of care, concurrent review, or service for which you received emergency Requests must be filed in writing at the services, and you have not been discharged following address, no later than four months from a facility. after you receive notice of the final adverse benefit determination: If our adverse benefit determination is that the service or treatment is investigational or Iowa Insurance Division experimental and your treating physician 1963 Bell Avenue, Suite 100 has certified in writing that delaying the Des Moines, IA 50315 service or treatment would render it Fax: 515-654-6500 significantly less effective, you may also E-mail: have the right to request an expedited [email protected] external review. How the review works. Upon You or your authorized representative may notification that an external review request submit an oral or written expedited external has been filed, Wellmark will make a review request to the Iowa Insurance preliminary review of the request to Division by contacting the Iowa Insurance determine whether the request may proceed Division at 877-955-1212. to external review. Following that review, the Iowa Insurance Division will decide If the Insurance Division determines the whether your request is eligible for an request is eligible for an expedited external external review, and if it is, the Iowa review, the Division will immediately assign Insurance Division will assign an an IRO to conduct the review and a decision independent review organization (IRO) to will be made expeditiously, but in no event conduct the external review. You will be more than 72 hours after the IRO receives advised of the name of the IRO and will the request for an expedited external review. then have five business days to provide new information to the IRO. The IRO will make Arbitration and Legal Action a decision within 45 days of the date the You shall not start arbitration or legal action Iowa Insurance Division receives your against us until you have exhausted the request for an external review. appeal procedure described in this section. Need help? You may contact the Iowa See the Arbitration and Legal Action Insurance Division at 877-955-1212 at any section and Governing Law, page 97, for time for assistance with the external review important information about your process. arbitration and legal action rights after you have exhausted the appeal procedures in Expedited External Review this section. You do not need to exhaust the internal appeal process to request an external review of an adverse determination or a final adverse determination if you have a medical condition for which the time frame for completing an internal appeal or for completing a standard external review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function. You may also have the right to request an expedited external review of a final adverse

Form Number: Wellmark IA Grp/AP_ 0121 87 CHRXST

13. Arbitration and Legal Action

PLEASE READ THIS SECTION making a claim through us or you, such as a CAREFULLY covered family member, employee, agent, representative, or an affiliated or subsidiary Mandatory Arbitration company. For purposes of this Arbitration You shall not start an action against us on and Legal Action section, the words “we,” any Claims (as defined below) unless you “us,” and “our” refer to Wellmark, Inc., and have first exhausted the appeal processes its subsidiaries and affiliates, the plan described in the Appeals section of this sponsor and/or the plan administrator, as coverage manual. well as their respective directors, officers, employees and agents. Except as solely discussed below, this section provides that Claims must be No Class Arbitrations and resolved by binding mandatory arbitration. Arbitration replaces the right to go to court, Class Actions Waiver have a jury trial or initiate or participate in a YOU UNDERSTAND AND AGREE THAT class action. In arbitration, disputes are YOU AND WE BOTH ARE VOLUNTARILY resolved by an arbitrator, not a judge or a AND IRREVOCABLY WAIVING THE jury. Arbitration procedures are simpler and RIGHT TO PURSUE OR HAVE A DISPUTE more limited than in court. RESOLVED AS A PLAINTIFF OR CLASS MEMBER IN ANY PURPORTED CLASS, Covered Claims COLLECTIVE OR REPRESENTATIVE Except as solely stated below, you or we PROCEEDING PENDING BETWEEN YOU must arbitrate any claim, dispute or AND US. YOU ARE AGREEING TO GIVE controversy arising out of or related to this UP THE ABILITY TO PARTICIPATE IN coverage manual or any other document CLASS ARBITRATIONS, CLASS ACTIONS related to your health plan, including, but AND ANY OTHER COLLECTIVE OR not limited to, member eligibility, benefits REPRESENTATIVE ACTIONS. Neither you under your health plan or administration of nor we consent to the incorporation of the your health plan (any and/or all of the AAA Supplementary Rules for Class foregoing called “Claims”). Arbitration into the rules governing the arbitration of Claims. The arbitrator has no Except as stated below, all Claims are authority to arbitrate any claim on a class or subject to mandatory arbitration, no matter representative basis and may award relief what legal theory they are based, whether in only on an individual basis. Claims of two or law or equity, upon or what remedy more persons may not be combined in the (damages, or injunctive or declaratory same arbitration, unless both you and we relief) they seek, including Claims based on agree to do so. contract, tort (including intentional tort), fraud, agency, your or our negligence, Claims Excluded from statutory or regulatory provisions, or any Mandatory Arbitration other sources of law; counterclaims, cross- ◼ Small Claims – individual Claims filed claims, third-party claims, interpleaders or in a small claims court are not subject to otherwise; Claims made regarding past, arbitration, as long as the matter stays present or future conduct; and Claims made in small claims court. independently or with other claims. This also includes Claims made by or against ◼ Claims Excluded By Applicable Law – anyone connected with us or you or federal or state law may exempt certain claiming through us or you, or by someone Claims from mandatory arbitration. IF

Form Number: Wellmark IA Grp/ALA_ 0121 89 CHRXST Arbitration and Legal Action

AN ARBITRATOR DETERMINES A of any emergency, temporary or PARTICULAR CLAIM IS preliminary injunctive relief granted by EXCLUDED FROM ARBITRATION the arbitrator. BY FEDERAL OR STATE LAW, ◼ Arbitration may be compelled at any CLAIMS EXCLUDED BY time by either party, even where there is APPLICABLE LAW, LATER IN a pending lawsuit in court, unless a trial THIS SECTION, AND GOVERNING has begun or a final judgment has been LAW, PAGE 97, WILL APPLY TO entered. Neither you nor we waive the THE PARTIES AND SUCH right to arbitrate by filing or serving a PARTICULAR CLAIM. complaint, answer, counterclaim, motion, or discovery in a court lawsuit. Arbitration Process Generally To invoke arbitration, a party may file a ◼ No demand for arbitration of a Claim motion to compel arbitration in a because of a health benefit claim under pending matter and/or commence this plan, or because of the alleged arbitration by submitting the required breach of this plan, shall be made more AAA forms and requisite filing fees to than two years after the end of the the AAA. calendar year in which the services or ◼ The arbitration shall be conducted by a supplies were provided. single arbitrator in accordance with this ◼ Arbitration shall be conducted by the arbitration provision and the AAA American Arbitration Association Rules, which may limit discovery. The (“AAA”) according to the Federal arbitrator shall not apply any federal or Arbitration Act (“FAA”) (to the exclusion state rules of civil procedure for of any state laws inconsistent discovery, but the arbitrator shall honor therewith), this arbitration provision claims of privilege recognized at law and and the applicable AAA Consumer shall take reasonable steps to protect Arbitration Rules in effect when the plan information and other confidential Claim is filed (“AAA Rules”), except information of either party if requested where those rules conflict with this to do so. The parties agree that the scope arbitration provision. You can obtain of discovery will be limited to non- copies of the AAA Rules at the AAA’s privileged information that is relevant to website (www.adr.org). You or we may the Claim, and consistent with the choose to have a hearing, appear at any parties’ intent, the arbitrator shall hearing by phone or other electronic ensure that allowed discovery is means, and/or be represented by reasonable in scope, cost-effective and counsel. Any in-person hearing will be non-onerous to either party. The held in the same city as the U.S. District arbitrator shall apply the FAA and other Court closest to your billing address. applicable substantive law not ◼ Either you or we may apply to a court inconsistent with the FAA, and may for emergency, temporary or award damages or other relief under preliminary injunctive relief or an order applicable law. in aid of arbitration (i) prior to the ◼ The arbitrator shall make any award in appointment of an arbitrator or (ii) after writing and, if requested by you or us, the arbitrator makes a final award and may provide a brief written statement of closes the arbitration. Once an arbitrator the reasons for the award. An arbitration has been appointed until the arbitration award shall decide the rights and is closed, emergency, temporary or obligations only of the parties named in preliminary injunctive relief may only be the arbitration and shall not have any granted by the arbitrator. Either you or bearing on any other person or dispute. we may apply to a court for enforcement

CHRXST 90 Form Number: Wellmark IA Grp/ALA_ 0121 Arbitration and Legal Action

IF ARBITRATION IS INVOKED BY Questions of Arbitrability ANY PARTY WITH RESPECT TO A You and we mutually agree that the CLAIM, NEITHER YOU NOR WE arbitrator, and not a court, will decide in the WILL HAVE THE RIGHT TO first instance all questions of substantive LITIGATE THAT CLAIM IN COURT arbitrability, including without limitation OR HAVE A JURY TRIAL ON THAT the validity of this Section, whether you and CLAIM, OR TO ENGAGE IN we are bound by it, and whether this Section PREARBITRATION DISCOVERY applies to a particular Claim. EXCEPT AS PROVIDED FOR IN THE APPLICABLE ARBITRATION RULES. Claims Excluded By THE ARBITRATOR’S DECISION Applicable Law WILL BE FINAL AND BINDING. YOU If an arbitrator determines a particular UNDERSTAND THAT OTHER Claim is excluded from arbitration by RIGHTS THAT YOU WOULD HAVE IF federal or state law, you and we agree that YOU WENT TO COURT MAY ALSO the following terms will apply to any legal or NOT BE AVAILABLE IN equitable action brought in court because of ARBITRATION. such Claim:

Arbitration Fees and Other ◼ You shall not bring any legal or Costs equitable action against us because of a The AAA Rules determine what costs you health benefit claim under this plan, or and we will pay to the AAA in connection because of the alleged breach of this with the arbitration process. In most plan, more than two years after the end instances, your responsibility for filing, of the calendar year in which the administrative and arbitrator fees to pursue services or supplies were provided. a Claim in arbitration will not exceed $200. ◼ Any action brought because of a Claim However, if the arbitrator decides that under this plan will be litigated in the either the substance of your claim or the state or federal courts located in the remedy you asked for is frivolous or brought state of Iowa and in no other. for an improper purpose, the arbitrator will ◼ YOU AND WE BOTH WAIVE ANY use the AAA Rules to determine whether RIGHT TO A JURY TRIAL WITH you or we are responsible for the filing, RESPECT TO AND IN ANY CLAIM. administrative and arbitrator fees. ◼ FURTHER, YOU AND WE BOTH You may wish to consult with or be WAIVE ANY RIGHT TO SEEK OR represented by an attorney during the RECOVER PUNITIVE OR arbitration process. Each party is EXEMPLARY DAMAGES WITH responsible for its own attorney’s fees and RESPECT TO ANY CLAIM. other expenses, such as witness fees and expert witness costs. Survival and Severability of Terms Confidentiality This Arbitration and Legal Action section The arbitration proceedings and arbitration will survive termination of the plan. If any award shall be maintained by the parties as portion of this provision is deemed invalid strictly confidential, except as is otherwise or unenforceable under any law or statute it required by court order, as is necessary to will not invalidate the remaining portions of confirm, vacate or enforce the award, and this Arbitration and Legal Action section or for disclosure in confidence to the parties’ the plan. To the extent a Claim qualifies for respective attorneys and tax advisors of a mandatory arbitration and there is a conflict party who is an individual. or inconsistency between the AAA Rules

Form Number: Wellmark IA Grp/ALA_ 0121 91 CHRXST Arbitration and Legal Action and this Arbitration and Legal Action section, this Arbitration and Legal Action section will govern.

CHRXST 92 Form Number: Wellmark IA Grp/ALA_ 0121

14. Your Rights Under ERISA

Continued Group Health Plan Employee Retirement Income Coverage Security Act of 1974 You have the right to continue health care Your rights concerning your coverage may coverage for yourself, spouse or dependents be protected by the Employee Retirement if there is a loss of coverage under the plan Income Security Act of 1974 (ERISA), a as a result of a qualifying event. However, federal law protecting your rights under this you or your dependents may have to pay for benefits plan. Any employee benefits plan such coverage. For more information on the established or maintained by an employer rules governing your COBRA continuation or employee organization or both is subject coverage rights, review this coverage to this federal law unless the benefits plan is manual and the documents governing the a governmental or church plan as defined in plan. See COBRA Continuation, page 73. ERISA. As a participant in this group health plan, Prudent Actions by Plan Fiduciaries you are entitled to certain rights and In addition to creating rights for plan protections under the Employee Retirement participants, ERISA imposes duties upon Income Security Act of 1974 (ERISA). the people responsible for the operation of your employee benefits plan. The people Receive Information About Your Plan who operate the plan, called fiduciaries of and Benefits the plan, have a duty to do so prudently and You may examine, without charge, at the in the interest of you and other plan plan administrator’s office or at other participants and beneficiaries. No one, specified locations, such as worksites and including your employer, your union, or any union halls, all documents governing the other person, may fire you or otherwise plan, including insurance contracts and discriminate against you in any way to collective bargaining agreements, and a prevent you from obtaining a welfare benefit copy of the latest annual report (Form 5500 or exercising your rights under ERISA. Series) filed by the plan with the U.S. Department of Labor and available at the Enforcement of Rights Public Disclosure Room of the Employee If your claim for a covered benefit is denied Benefits Security Administration. or ignored, in whole or in part, you have a right to know why this was done, to obtain You may obtain, upon written request to the copies of documents relating to the decision plan administrator, copies of documents without charge, and to appeal any denial, all governing the operation of the plan, within certain time schedules. including insurance contracts and collective bargaining agreements, and copies of the Under ERISA, there are steps you can take latest annual report (Form 5500 Series) and to enforce the above rights. For instance, if updated summary plan description. The you request a copy of plan documents or the plan administrator may make a reasonable latest annual report from the plan and do charge for the copies. not receive them within 30 days, you may file suit in federal court. In such a case, the You may also obtain a summary of the court may require the plan administrator to plan’s annual financial report. The plan provide the materials and pay you up to administrator is required by law to furnish $110 a day until you receive the materials, you with a copy of this summary annual unless the materials were not sent because report. of reasons beyond the control of the plan administrator. If you have a claim for

Form Number: Wellmark IA Grp/ER_ 0119 93 CHRXST Your Rights Under ERISA benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the plan’s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in federal court. If it should happen that plan fiduciaries misuse the plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

Assistance With Your Questions If you have any questions about your plan, you should contact the plan administrator. If you have questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the plan administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in the telephone directory, or write to: Division of Technical Assistance and Inquiries Employee Benefits Security Administration U.S. Department of Labor 200 Constitution Avenue, N.W. Washington, D.C. 20210 You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

CHRXST 94 Form Number: Wellmark IA Grp/ER_ 0119

15. General Provisions

administrator as the twelve month period Contract commencing on the effective date of your The conditions of your coverage are defined group health plan's annual renewal with in your contract. Your contract includes: Wellmark. ◼ Any application you submitted to us or Authority to Terminate, to your employer or group sponsor. Amend, or Modify ◼ Any agreement or group policy we have Your employer or group sponsor has the with your employer or group sponsor. authority to terminate, amend, or modify ◼ Any application completed by your the coverage described in this coverage employer or group sponsor. manual at any time. Any amendment or ◼ This coverage manual and any modification will be in writing and will be as amendments. binding as this coverage manual. If your All of the statements made by you or your contract is terminated, you may not receive employer or group sponsor in any of these benefits. materials will be treated by us as representations, not warranties. Authorized Group Benefits Plan Changes Interpreting this Coverage No agent, employee, or representative of Manual ours is authorized to vary, add to, change, We will interpret the provisions of this modify, waive, or alter any of the provisions coverage manual and determine the answer described in this coverage manual. This to all questions that arise under it. We have coverage manual cannot be changed except the administrative discretion to determine by one of the following: whether you meet our written eligibility ◼ Written amendment signed by an requirements, or to interpret any other term authorized officer and accepted by you in this coverage manual. If any benefit or your employer or group sponsor or as described in this coverage manual is subject shown by payment of the premium. to a determination of medical necessity, unless otherwise required by law, we will ◼ Our receipt of proper notification that make that factual determination. Our an event has changed your spouse or interpretations and determinations are final dependent's eligibility for coverage. See and conclusive, subject to the appeal Coverage Changes and Termination, procedures outlined earlier in this coverage page 71. manual. Member Participation There are certain rules you must follow in Information will be made available to order for us to properly administer your members regarding matters such as benefits. Different rules appear in different wellness, general health education, and sections of your coverage manual. You matters of policy and operation of Wellmark should become familiar with the entire Health Plan of Iowa, Inc. document. Authorized Representative Plan Year You may authorize another person to The Plan Year has been designated and represent you and with whom you want us communicated to Wellmark by your group to communicate regarding specific claims or health plan’s plan sponsor or plan an appeal. This authorization must be in

Form Number: Wellmark IA Grp/GP_ 0121 95 CHRXST General Provisions writing, signed by you, and include all the Treatment information required in our Authorized We may disclose your health information to Representative Form. This form is available a physician or other health care provider in at Wellmark.com or by calling the Customer order for such health care provider to Service number on your ID card. provide treatment to you. In a medically urgent situation your treating Payment health care practitioner may act as your We may use and disclose your health authorized representative without information to pay for covered services from completion of the Authorized physicians, hospitals, and other providers, Representative Form. to determine your eligibility for benefits, to An assignment of benefits, release of coordinate benefits, to determine medical information, or other similar form that you necessity, to obtain premiums, to issue may sign at the request of your health care explanations of benefits to the person provider does not make your provider an enrolled in the group health plan in which authorized representative. You may you participate, and the like. We may authorize only one person as your disclose your health information to a health representative at a time. You may revoke the care provider or entity subject to the federal authorized representative at any time. privacy rules so they can obtain payment or engage in these payment activities. Release of Information Health Care Operations By enrolling in this group health plan, you We may use and disclose your health have agreed to release any necessary information in connection with health care information requested about you so we can operations. Health care operations include, process claims for benefits. but are not limited to, rating our risk and You must allow any provider, facility, or determining premiums for your group their employee to give us information about health plan; quality assessment and a treatment or condition. If we do not improvement activities; reviewing the receive the information requested, or if you competence or qualifications of health care withhold information, your benefits may be practitioners, evaluating provider denied. If you fraudulently use your performance, conducting training programs, coverage or misrepresent or conceal accreditation, certification, licensing, or material facts when providing information, credentialing activities; medical review, then we may terminate your coverage under legal services, and auditing, including fraud this group health plan. and abuse detection and compliance; business planning and development; and Privacy of Information business management and general We are committed to protecting the privacy administrative activities. of your health information. We will request, Other Disclosures use, or disclose your health information We will obtain your explicit authorization only as permitted or required by law. for any use or disclosure of your health Wellmark has issued a Privacy Practices information that is not permitted or Notice. This notice is available upon request required by law. For example, we may or at Wellmark.com. release claim payment information to a We will use or disclose your health friend or family member to act on your information for treatment, payment, and behalf during a hospitalization if you submit health care operations according to the an authorization to release information to standards and specifications of the federal that person. If you give us an authorization, privacy regulations. you may revoke it in writing at any time.

CHRXST 96 Form Number: Wellmark IA Grp/GP_ 0121 General Provisions

Your revocation will not affect any use or Value-Based Programs disclosures permitted by your authorization Value-based programs involve local health while it was in effect. care organizations that are held accountable for the quality and cost of care delivered to a Member Health Support defined population. Value-based programs Services can include accountable care organizations Wellmark may from time to time make (ACOs), patient centered medical homes available to you certain health support (PCMHs), and other programs developed by services (such as disease management), for Wellmark, the Blue Cross Blue Shield a fee or for no fee. Wellmark may offer Association, or other Blue Cross Blue Shield financial and other incentives to you to use health plans (“Blue Plans”). Wellmark and such services. As a part of the provision of Blue Plans have entered into collaborative these services, Wellmark may: arrangements with value-based programs under which the health care providers ◼ Use your personal health information (including, but not limited to, substance participating in them are eligible for abuse, mental health, and HIV/AIDS financial incentives relating to quality and information); and cost-effective care of Wellmark and/or Blue Plan members. If your physician, hospital, ◼ Disclose such information to your health or other health care provider participates in care providers and Wellmark’s health the Wellmark ACO program or other value- support service vendors, for purposes of based program, Wellmark may make providing such services to you. available to such health care providers your Wellmark will use and disclose information health care information, including claims according to the terms of our Privacy information, for purposes of helping Practices Notice, which is available upon support their delivery of health care services request or at Wellmark.com. to you. Value Added or Innovative Nonassignment Benefits Except as required by law, benefits for Wellmark may, from time to time, make covered services under this group health available to you certain value added or plan are for your personal benefit and innovative benefits for a fee or for no fee. cannot be transferred or assigned to anyone Examples include Blue365®, identity theft else without our consent. Whether made protections, and discounts on before or after services are provided, you are alternative/preventive therapies, fitness, prohibited from assigning any claim. You exercise and diet assistance, and elective are further prohibited from assigning any procedures as well as resources to help you cause of action arising out of or relating to make more informed health decisions. this group health plan. Any attempt to Wellmark may also provide rewards or assign this group health plan, even if incentives under this plan if you participate assignment includes the provider’s rights to in certain voluntary wellness activities or receive payment, will be null and void. programs that encourage healthy behaviors. Nothing contained in this group health plan Your employer is responsible for any shall be construed to make the health plan income and employment tax withholding, or Wellmark liable to any third party to depositing and reporting obligations that whom a member may be liable for medical may apply to the value of such rewards and care, treatment, or services. incentives. Governing Law To the extent not superseded by the laws of the United States, the group health plan will

Form Number: Wellmark IA Grp/GP_ 0121 97 CHRXST General Provisions be construed in accordance with and ◼ Underinsured motorist coverage; governed by the laws of the state of Iowa. ◼ Personal umbrella coverage; ◼ Other insurance coverage including, but Medicaid Enrollment and not limited to, homeowner’s, motor Payments to Medicaid vehicle, or medical payments insurance; and Assignment of Rights This group health plan will provide payment ◼ Any other payment from a source of benefits for covered services to you, your intended to compensate you for injuries beneficiary, or any other person who has resulting from an accident or alleged been legally assigned the right to receive negligence. such benefits under requirements Right of Subrogation established pursuant to Title XIX of the If you or your legal representative have a Social Security Act (Medicaid). claim to recover money from a third party Enrollment Without Regard to and this claim relates to an illness or injury Medicaid for which Wellmark provides benefits, Your receipt or eligibility for medical Wellmark will be subrogated to you and assistance under Title XIX of the Social your legal representative’s rights to recover Security Act (Medicaid) will not affect your from the third party as a condition to your enrollment as a participant or beneficiary of receipt of benefits. this group health plan, nor will it affect our Right of Reimbursement determination of any benefits paid to you. If you have an illness or injury as a result of Acquisition by States of Rights of the act of a third party or arising out of Third Parties obligations you have under a contract and If payment has been made by Medicaid and you or your legal representative files a claim Wellmark has a legal obligation to provide under this group health plan, as a condition benefits for those services, Wellmark will of receipt of benefits, you or your legal make payment of those benefits in representative must reimburse Wellmark accordance with any state law under which a for all benefits paid for the illness or injury state acquires the right to such payments. from money received from the third party or its insurer, or under the contract, to the Medicaid Reimbursement extent of the amount paid by Wellmark on When a Wellmark Blue POS Provider the claim. submits a claim to a state Medicaid program for a covered service and Wellmark Once you receive benefits under this group reimburses the state Medicaid program for health plan arising from an illness or injury, the service, Wellmark’s total payment for Wellmark will assume any legal rights you the service will be limited to the amount have to collect compensation, damages, or paid to the state Medicaid program. No any other payment related to the illness or additional payments will be made to the injury from any third party. provider or to you. You agree to recognize Wellmark’s rights to subrogation and reimbursement. These Subrogation rights provide Wellmark with a priority over For purposes of this “Subrogation” section, any money paid by a third party to you “third party” includes, but is not limited to, relative to the amount paid by Wellmark, any of the following: including priority over any claim for nonmedical charges, or other costs and ◼ The responsible person or that person’s expenses. Wellmark will assume all rights of insurer; recovery, to the extent of payment, ◼ Uninsured motorist coverage; regardless of whether payment is made

CHRXST 98 Form Number: Wellmark IA Grp/GP_ 0121 General Provisions

before or after settlement of a third party ◼ Prior to settlement, all information claim, and regardless of whether you have related to any oral or written settlement received full or complete compensation for agreement between you and the third an illness or injury. party or his insurer or your insurer; ◼ All information regarding any legal Procedures for Subrogation and action that has been brought on your Reimbursement behalf against the third party or his You or your legal representative must do insurer; and whatever Wellmark requests with respect to the exercise of Wellmark’s subrogation and ◼ All other information requested by reimbursement rights, and you agree to do Wellmark. nothing to prejudice those rights. In Send this information to: addition, at the time of making a claim for Wellmark Health Plan of Iowa, Inc. benefits, you or your legal representative 1331 Grand Avenue, Station 5W580 must inform Wellmark in writing if you Des Moines, IA 50309-2901 have an illness or injury caused by a third party or arising out of obligations you have You also agree to all of the following: under a contract. You or your legal ◼ You will immediately let us know about representative must provide the following any potential claims or rights of recovery information, by registered mail, as soon as related to the illness or injury. reasonably practicable of such illness or ◼ You will furnish any information and injury to Wellmark as a condition to receipt assistance that we determine we will of benefits: need to enforce our rights under this ◼ The name, address, and telephone group health plan. number of the third party that in any ◼ You will do nothing to prejudice our way caused the illness or injury or is a rights and interests including, but not party to the contract, and of the attorney limited to, signing any release or waiver representing the third party; (or otherwise releasing) our rights, ◼ The name, address and telephone without obtaining our written number of the third party’s insurer and permission. any insurer of you; ◼ You will not compromise, settle, ◼ The name, address and telephone surrender, or release any claim or right number of your attorney with respect to of recovery described above, without the third party’s act; obtaining our written permission. ◼ Prior to the meeting, the date, time and ◼ If payment is received from the other location of any meeting between the party or parties, you must reimburse us third party or his attorney and you, or to the extent of benefit payments made your attorney; under this group health plan. ◼ All terms of any settlement offer made ◼ In the event you or your attorney receive by the third party or his insurer or your any funds in compensation for your insurer; illness or injury, you or your attorney ◼ All information discovered by you or will hold those funds (up to and your attorney concerning the insurance including the amount of benefits paid by coverage of the third party; Wellmark in connection with the illness or injury) in trust for the benefit of ◼ The amount and location of any money Wellmark as trustee(s) for Wellmark that is recovered by you from the third until the extent of our right to party or his insurer or your insurer, and reimbursement or subrogation has been the date that the money was received; resolved.

Form Number: Wellmark IA Grp/GP_ 0121 99 CHRXST General Provisions

◼ In the event you invoke your rights of that is the subject or basis of a workers’ recovery against a third-party related to compensation claim (whether litigated or the illness or injury, you will not seek an not), we are entitled to reimbursement to advancement of costs or fees from the extent benefits are paid under this plan Wellmark. in the event that your claim is accepted or It is further agreed that in the event that you adjudged to be covered under workers’ fail to take the necessary legal action to compensation. recover from the responsible party, Furthermore, we are entitled to Wellmark shall have the option to do so and reimbursement from you to the full extent may proceed in its name or your name of benefits paid out of any proceeds you against the responsible party and shall be receive from any workers’ compensation entitled to the recovery of the amount of claim, regardless of whether you have been benefits paid under this group health plan made whole or fully compensated for your and shall be entitled to recover its expenses, losses, regardless of whether the proceeds including reasonable attorney fees and represent a compromise or disputed costs, incurred for such recovery. settlement, and regardless of any In the event Wellmark deems it necessary to characterization of the settlement proceeds institute legal action against you if you fail by the parties to the settlement. We will not to repay Wellmark as required in this group be liable for any attorney’s fees or other health plan, you shall be liable for the expenses incurred in obtaining any proceeds amount of such payments made by for any workers’ compensation claim. Wellmark as well as all of Wellmark’s costs We utilize industry standard methods to of collection, including reasonable attorney identify claims that may be work-related. fees and costs. This may result in initial payment of some You and your covered family member(s) claims that are work-related. We reserve the must notify us if you have the potential right right to seek reimbursement of any such to receive payment from someone else. You claim or to waive reimbursement of any must cooperate with us to ensure that our claim, at our discretion. rights to subrogation are protected. Payment in Error Wellmark’s right of subrogation and If for any reason we make payment in error, reimbursement under this group health we may recover the amount we paid. plan applies to all rights of recovery, and not only to your right to compensation for If we determine we did not make full medical expenses. A settlement or judgment payment, Wellmark will make the correct structured in any manner not to include payment without interest. medical expenses, or an action brought by you or on your behalf which fails to state a Premium claim for recovery of medical expenses, shall Your employer or group sponsor must pay not defeat our rights of subrogation and us in advance of the due date assigned for reimbursement if there is any recovery on your coverage. For example, payment must your claim. be made prior to the beginning of each calendar month, each quarter, or each year, We reserve the right to offset any amounts depending on your specific due date. owed to us against any future claim payments. If you misrepresent any information to Wellmark relating to this coverage, Workers’ Compensation Wellmark may, in addition to exercising any If you have received benefits under this other available remedies, retroactively group health plan for an injury or condition adjust the monthly premiums for this

CHRXST 100 Form Number: Wellmark IA Grp/GP_ 0121 General Provisions coverage as if the information in question employer or to Wellmark, you give express had been correctly represented in the consent to Wellmark to contact you using application for coverage. the email address or residential or cellular telephone number provided via live or pre- Notice recorded voice call, or text message If a specific address has not been provided notification or email notification. Wellmark elsewhere in this coverage manual, you may may contact you for purposes of providing send any notice to Wellmark’s home office: important information about your plan and benefits, or to offer additional products and Wellmark Health Plan of Iowa, Inc. services related to your Wellmark plan. You 1331 Grand Avenue may revoke this consent by following Des Moines, IA 50309-2901 instructions given to you in the email, text Any notice from Wellmark to you is or call notifications, or by telling the acceptable when sent to your address as it Wellmark representative that you no longer appears on Wellmark’s records or the want to receive calls. address of the group through which you are enrolled.

Inspection of Coverage Except for groups that maintain a cafeteria plan pursuant to Section 125 of the Internal Revenue Code (26 USCA § 125), a member may, if evidence of coverage is not satisfactory for any reason, return the evidence of coverage within 10 days of its receipt and receive full refund of the deposit paid, if any. This right will not act as a cure for misleading or deceptive advertising or marketing methods, nor may it be exercised if the member utilizes the services of the HMO within the 10-day period. Members in cafeteria plans must adhere to the plan provisions concerning termination or changes in coverage. Submitting a Complaint If you are dissatisfied or have a complaint regarding our products or services, call the Customer Service number on your ID card. We will attempt to resolve the issue in a timely manner. You may also contact Customer Service for information on where to send a written complaint. Consent to Telephone Calls and Text or Email Notifications By enrolling in this employer sponsored group health plan, and providing your phone number and email address to your

Form Number: Wellmark IA Grp/GP_ 0121 101 CHRXST

Glossary

The definitions in this section are terms that are used in various sections of this coverage manual. A term that appears in only one section is defined in that section.

Accidental Injury. An injury, ◼ Group health plan (including independent of disease or bodily infirmity government and church plans). or any other cause, that happens by chance ◼ Health insurance coverage (including and requires immediate medical attention. group, individual, and short-term Admission. Formal acceptance as a limited duration coverage). patient to a hospital or other covered health ◼ Medicare (Part A or B of Title XVIII of care facility for a health condition. the Social Security Act). ◼ Medicaid (Title XIX of the Social Amount Charged. The amount that a Security Act). provider bills for a service or supply or the retail price that a pharmacy charges for a ◼ Medical care for members and certain prescription drug, whether or not it is former members of the uniformed covered under this group health plan. services, and for their dependents (Chapter 55 of Title 10, United States Backup Provider. Your designated Code). personal doctor’s designated backup when ◼ A medical care program of the Indian your personal doctor is not available. A Health Service or of a tribal backup provider is in the Wellmark Blue organization. POS network and performs the same ◼ A state health benefits risk pool. functions as a designated personal doctor. ◼ Federal Employee Health Benefit Plan (a Benefits. Medically necessary services or health plan offered under Chapter 89 of supplies that qualify for payment under this Title 5, United States Code). group health plan. ◼ A State Children’s Health Insurance BlueCard Program. The Blue Cross Blue Program (S-CHIP). Shield Association program that permits ◼ A public health plan as defined in members of any Blue Cross or Blue Shield federal regulations (including health Plan to have access to the advantages of coverage provided under a plan Wellmark Blue POS Providers throughout established or maintained by a foreign the United States. country or political subdivision). Compounded Drugs. Compounded ◼ A health benefits plan under Section prescription drugs are produced by 5(e) of the Peace Corps Act. combining, mixing, or altering ingredients ◼ An organized delivery system licensed by a pharmacist to create an alternate by the director of public health. strength or dosage form tailored to the Extended Home Skilled Nursing. specialized medical needs of an individual Home skilled nursing care, other than patient when an FDA-approved drug is short-term home skilled nursing, provided unavailable or a licensed health care in the home by a registered (R.N.) or provider decides that an FDA-approved licensed practical nurse (L.P.N.) who is drug is not appropriate for a patient’s associated with an agency accredited by the medical needs. Joint Commission for Accreditation of Creditable Coverage. Any of the Health Care Organizations (JCAHO) or a following categories of coverage: Medicare-certified agency that is ordered by a physician and consists of four or more hours per day of continuous nursing care

Form Number: Wellmark IA Grp/GL_ 0121 103 CHRXST Glossary that requires the technical proficiency and under Social Security or the Railroad knowledge of an R.N. or L.P.N. Retirement Program. It is also for those with chronic renal disease who require Group. Those plan members who share a hemodialysis or kidney transplant. common relationship, such as employment or membership. Member. A person covered under this group health plan. Group Sponsor. The entity that sponsors this group health plan. Nonparticipating Pharmacy. A pharmacy that does not participate with the Habilitative Services. Health care network used by your prescription drug services that help a person keep, learn, or benefits. improve skills and functioning for daily living. Examples include therapy for a child Office. An office setting is the room or who isn’t walking or talking at the expected rooms in which the practitioner or staff age. These services may include physical provide patient care. and occupational therapy, speech-language Out-of-Network Provider. A facility or pathology and other services for people with practitioner that does not participate with disabilities in a variety of inpatient and/or either the Wellmark Blue POS network or a outpatient settings. Blue Cross or Blue Shield Plan in any other Illness or Injury. Any bodily disorder, state. Pharmacies that do not contract with bodily injury, disease, or mental health our pharmacy benefits manager are condition, including pregnancy and considered Out-of-Network Providers. complications of pregnancy. Outpatient. Services received, or a person Inpatient. Services received, or a person receiving services, in the outpatient receiving services, while admitted to a department of a hospital, an ambulatory health care facility for at least an overnight surgery center, or the home. stay. Participating Pharmacy. A pharmacy Medical Appliance. A device or that participates with the network used by mechanism designed to support or restrain your prescription drug benefits. Pharmacies part of the body (such as a splint, bandage that do not contract with our pharmacy or brace); to measure functioning or benefits manager are considered Out-of- physical condition of the body (such as Network Providers. glucometers or devices to measure blood Participating Providers. These pressure); or to administer drugs (such as providers participate with a Blue Cross syringes). and/or Blue Shield Plan, but not with the Medically Urgent. A situation where a Wellmark Blue POS network. longer, non-urgent response time could Plan. The group health benefits program seriously jeopardize the life or health of the offered to you as an eligible employee for plan member seeking services or, in the purposes of ERISA. opinion of a physician with knowledge of the member’s medical condition, would Plan Administrator. The employer or subject the member to severe pain that group sponsor of this group health plan for cannot be managed without the services in purposes of the Employee Retirement question. Income Security Act. Medicare. The federal government health Plan Member. The person who signed for insurance program established under Title this group health plan. XVIII of the Social Security Act for people age 65 and older and for individuals of any age entitled to monthly disability benefits

CHRXST 104 Form Number: Wellmark IA Grp/GL_ 0121 Glossary

Plan Year. A date used for purposes of determining compliance with federal legislation. Services or Supplies. Any services, supplies, treatments, devices, or drugs, as applicable in the context of this coverage manual, that may be used to diagnose or treat a medical condition. Specialty Drugs. Drugs that are typically used for treating or managing chronic illnesses. These drugs are subject to restricted distribution by the U.S. Food and Drug Administration or require special handling, provider coordination, or patient education that may not be provided by a retail pharmacy. Some specialty drugs may be taken orally, but others may require administration by injection or inhalation. Spouse. A man or woman lawfully married to a covered member. Urgent Care Centers provide medical care without an appointment during all hours of operation to walk-in patients of all ages who are ill or injured and require immediate care but may not require the services of a hospital emergency room. We, Our, Us. Wellmark Health Plan of Iowa, Inc. Wellmark Blue POS Provider. A facility or practitioner that participates with Wellmark Health Plan of Iowa, Inc. X-ray and Lab Services. Tests, screenings, imagings, and evaluation procedures identified in the American Medical Association's Current Procedural Terminology (CPT) manual, Standard Edition, under Radiology Guidelines and Pathology and Laboratory Guidelines. You, Your. The plan member and family members eligible for coverage under this group health plan.

Form Number: Wellmark IA Grp/GL_ 0121 105 CHRXST

Index

A bone marrow transplants ...... 31 braces ...... 21, 24, 30 abuse of drugs ...... 35 brain injuries ...... 57 accident deductible ...... 5 brand name drugs ...... 64 accidental injury ...... 18 breast reconstruction ...... 30 acupressure ...... 15 acupuncture ...... 11, 15 C addiction ...... 12, 17 capitation ...... 62 administrative services ...... 12, 26, 39 care coordination ...... 53 admissions ...... 53, 54 case management ...... 57 adoption ...... 67, 71 changes of coverage...... 71, 72 advanced registered nurse practitioners ..... 13, 27 chemical dependency ...... 12, 17 allergy services ...... 11, 15 chemical dependency treatment facility ...... 22 ambulance services ...... 11, 15 chemotherapy ...... 12, 17 ambulatory facility ...... 22 child support order ...... 68 ambulatory facility services ...... 19 children ...... 67, 68, 71, 81 amount charged ...... 61, 65 chiropractic services ...... 12, 26, 45 anesthesia ...... 11, 16, 19 chiropractors ...... 13, 27 annulment ...... 71, 72 claim filing ...... 75, 79 antigen therapy ...... 28, 34 claim forms ...... 75 appeals ...... 53, 85 claim payment ...... 76 applied behavior analysis ...... 16 claims ...... 75 arbitration ...... 89, 90, 91 claims excluded by applicable law ...... 91 arbitration fees ...... 91 class actions waiver ...... 89 artificial insemination ...... 20 clinical trials ...... 12, 17 assignment of benefits ...... 97, 98 COBRA coverage ...... 71, 73 audiologists ...... 13, 27 coinsurance ...... 4, 6, 9, 59 authority to terminate or amend ...... 95 common accident deductible ...... 5 authorized representative ...... 95 communication disorders ...... 25 autism ...... 11, 16 community mental health center ...... 22 B complaints ...... 101 complications ...... 39 benefit coordination ...... 79 compounded drugs...... 34 benefit levels ...... 3, 43 concurrent review...... 56 benefit year...... 59, 63 conditions of coverage ...... 37 benefit year deductible ...... 5 confidentiality...... 91 benefits maximums ...... 7, 11 contact lenses ...... 32 bereavement counseling ...... 18 contraceptive devices ...... 35 biological products ...... 28 contraceptives...... 12, 18 blood ...... 11, 17 contract ...... 95 BlueCard program ...... 46, 59 contract amendment ...... 95

107 CHRXST Index contract interpretation ...... 95, 97 drugs ...... 13, 28, 32, 63 convenience items ...... 12, 24 drugs that are not FDA-approved ...... 29, 34 convenience packaging ...... 35 E conversion therapy ...... 12, 18 education ...... 12, 18 coordination of benefits ...... 79 effective date ...... 68 coordination of care ...... 53 eligibility for coverage ...... 67, 71 copayment ...... 4, 6, 9 emergency room copayment ...... 4, 6 cosmetic drugs ...... 35 emergency services ...... 12, 20, 49 cosmetic services ...... 12, 18 employment physicals...... 30 cosmetic surgery ...... 13, 30 EOB (explanation of benefits) ...... 76 counseling ...... 12, 18 ERISA...... 93 coverage changes ...... 71, 72, 95 exclusions ...... 37, 38 coverage continuation ...... 73 expedited external review ...... 87 coverage effective date...... 68 experimental services ...... 38 coverage eligibility ...... 67, 71 explanation of benefits (EOB) ...... 76 coverage termination ...... 72, 73 eye services ...... 14, 32 covered claims...... 89 eyeglasses ...... 32 creditable coverage ...... 71 custodial care ...... 21 F cystic fibrosis...... 57 facilities ...... 12, 22 D family counseling ...... 18 family deductible ...... 5 damaged drugs ...... 35 family member as provider ...... 39 death ...... 71 FDA-approved A-rated generic drug ...... 64 deductible ...... 5 fertility services ...... 12, 20 deductible amounts ...... 4 filing claims ...... 75, 79 degenerative muscle disorders...... 57 foot care (routine) ...... 23 dental services ...... 12, 18 foot doctors ...... 13, 27 dependents ...... 67, 68, 71, 81 foreign countries ...... 35, 48 DESI drugs ...... 28 foster children ...... 67, 71 diabetes ...... 12, 19 fraud ...... 73 diabetic education...... 12, 19 diabetic supplies ...... 24 G dialysis ...... 12, 19 generic drugs ...... 64 dietary products ...... 12, 18, 26, 35 genetic testing ...... 12, 20 disabled dependents ...... 67 government programs ...... 39, 79 divorce ...... 71, 72 guest membership ...... 50 doctors ...... 13, 27 gynecological examinations ...... 13, 29 doctors of osteopathy ...... 13, 27 H drug abuse ...... 12, 17, 35 hairpieces ...... 14, 32 drug prior authorization ...... 57 hearing services ...... 12, 20 drug quantities ...... 35, 65 hemophilia ...... 57 drug rebates ...... 62, 66 high risk pregnancy ...... 57 drug refills ...... 35 home health services ...... 12, 21 drug tiers ...... 63, 64

CHRXST 108 Index home infusion therapy ...... 28 mammograms ...... 13, 29 home office (Wellmark) ...... 101 marriage ...... 71 home/durable medical equipment ...... 12, 21, 22 marriage counseling ...... 18 hospice respite care ...... 22 massage therapy ...... 26 hospice services ...... 12, 22 mastectomy...... 30 hospital services ...... 19, 73 maternity services ...... 12, 23 hospitals ...... 12, 22 maximum allowable fee ...... 61, 65 I medicaid enrollment ...... 98 medicaid reimbursement ...... 98 ID card ...... 44, 46, 51 medical doctors ...... 13, 27 illness ...... 12, 23 medical equipment ...... 12, 21, 22, 35 impacted teeth ...... 19 medical supplies ...... 12, 24 infertility drugs ...... 35 medical support order ...... 68 infertility treatment ...... 12, 20 medically necessary ...... 37 information disclosure ...... 96 Medicare ...... 71, 79 infused drugs ...... 35 medication therapy management ...... 28, 35 inhalation therapy ...... 12, 21, 23 medicines ...... 13, 28, 32, 63 injury ...... 12, 23 mental health services...... 12, 25 inpatient facility admission ...... 53, 54 mental health treatment facility ...... 22 inpatient services ...... 59, 73 mental illness ...... 12, 25 inspection of coverage ...... 101 military service ...... 39 insulin ...... 29 misrepresentation of material facts ...... 73 investigational or experimental drugs ...... 34 motor vehicles ...... 12, 26 investigational services ...... 38 muscle disorders ...... 57 irrigation solutions and supplies ...... 35 musculoskeletal treatment ...... 12, 26 K N kidney dialysis ...... 19 network chiropractors ...... 43 L network occupational therapists ...... 43, 45 L.P.N...... 21 network physical therapists ...... 43, 45 laboratory services ...... 14, 32 network providers ...... 43, 60 late enrollees ...... 68 network savings ...... 61 licensed independent social workers ...... 13, 27 network speech pathologists ...... 43, 45 licensed practical nurses ...... 21 newborn children ...... 71 lifetime benefits maximum ...... 40 nicotine dependence ...... 29, 30 limitations of coverage ...... 7, 11, 37, 40, 65 nicotine dependency drugs ...... 34 lodging ...... 13, 32 nonassignment of benefits ...... 97 long term acute care facility ...... 23 nonmedical services ...... 12, 26, 39 long term acute care services ...... 23 nonparticipating pharmacies ...... 34, 51, 65 lost or stolen items ...... 35 notice ...... 101 M notification of change ...... 72 notification requirements ...... 53 mail order drug program ...... 52 nursing facilities ...... 23, 73 mail order drugs ...... 52 nutrition education ...... 12, 19 mammogram (3D) ...... 29 nutritional products ...... 12, 18, 26

109 CHRXST Index

O prior approval ...... 40, 55 prior authorization ...... 40, 57 occupational therapists ...... 13, 27 privacy ...... 96 occupational therapy ...... 13, 21, 26 prosthetic devices ...... 13, 21, 30 office visit copayment ...... 4, 6 provider network ...... 3, 43, 60 optometrists ...... 13, 27 psychiatric medical institution for children oral contraceptives ...... 18 (PMIC) ...... 23 oral surgeons ...... 13, 27 psychiatric services ...... 25 organ transplants ...... 13, 31 psychologists ...... 13, 27 orthotics (foot) ...... 13, 27 pulmonary therapy ...... 12, 21, 23 osteopathic doctors ...... 13, 27 other insurance ...... 39, 79 Q out-of-area coverage ...... 35, 46, 59 qualified medical child support order ...... 68 out-of-network providers ...... 61 quantity limits ...... 35, 65 out-of-pocket maximum ...... 4, 5, 6, 9 R oxygen ...... 21, 24 R.N...... 13, 21, 24, 27 P radiation therapy ...... 12, 17 packaging ...... 35 rebates ...... 62, 66 Pap smears ...... 13, 29 reconstructive surgery ...... 13, 30 participating pharmacies ...... 34, 51, 65 referrals ...... 45 participating providers ...... 43, 60 refills ...... 35 payment arrangements ...... 61, 66 registered nurses ...... 13, 21, 24, 27 payment in error ...... 100 reimbursement of benefits...... 98, 100 payment obligations .... 4, 7, 10, 37, 41, 54, 59, 63, release of information ...... 96 64 removal from coverage ...... 71 personal doctor ...... 43, 44 respiratory therapy...... 12, 21, 23 personal items ...... 12, 24 rights of appeal ...... 85 physical examinations ...... 13, 29 routine services ...... 13, 29 physical therapists ...... 13, 27 S physical therapy ...... 13, 21, 27 physician assistants ...... 13, 27 self-help ...... 13, 31 physicians ...... 13, 27 separation ...... 71, 72 plan year ...... 95 service area ...... 46 plastic surgery ...... 12, 18 short-term home skilled nursing ...... 21 podiatrists ...... 13, 27 skilled nursing services ...... 12, 21, 23 practitioners ...... 13, 27 sleep apnea ...... 13, 31 precertification...... 40, 53 social adjustment ...... 13, 31 pregnancy ...... 23 social workers ...... 13, 27 pregnancy (high risk) ...... 57 specialty drugs ...... 28 premiums ...... 100 specialty pharmacy program ...... 34, 51 prenatal services ...... 23 speech pathologists ...... 13, 27 prescription drugs ...... 13, 28, 32, 63, 64 speech therapy ...... 13, 31 preventive care ...... 13, 29, 45 spinal cord injuries ...... 57 preventive items ...... 33 sports physicals ...... 30 preventive services...... 33 spouses ...... 67, 71

CHRXST 110 Index stepchildren ...... 67 travel physicals ...... 30 sterilization ...... 20 tubal ligation ...... 20 students ...... 67, 71 U subrogation ...... 98 urgent care center ...... 23 surgery ...... 13, 31 surgical facility ...... 22 V surgical facility services ...... 19 vaccines ...... 28 surgical supplies ...... 12, 24 vasectomy ...... 20 survival and severability of terms ...... 91 vehicles ...... 12, 26 T vision examinations ...... 45 vision services ...... 14, 32 take-home drugs ...... 28, 33 telehealth ...... 13, 31 W telehealth services copayment ...... 4, 6 weight reduction drugs ...... 35 temporomandibular joint disorder ...... 13, 31 well-child care ...... 13, 29 termination of coverage ...... 72, 73 Wellmark Blue POS provider ...... 3 therapeutic devices ...... 35 Wellmark drug list ...... 63 third party liability ...... 39 wigs ...... 14, 32 TMD (temporomandibular joint disorder) . 13, 31 workers’ compensation ...... 39, 100 tooth removal ...... 19 X transplants ...... 13, 31, 57 x-rays...... 14, 32 travel ...... 13, 32

111 CHRXST

112 CHRXST