S U M M A R Y P L A N

D E S C R I P T I O N

Casey's General Stores, Inc., Employee

Healthcare Benefit Plan

Group Effective Date: 1/1/2013

Plan Year: 01/01
Coverage Code: ZY7 5AQ ZY8 5AR
 Medical Benefits Plan
and
Prescription Drugs Benefits Plan

Casey's General Stores, Inc.

Premium and Standard Plans

NOTICE
This group health plan is sponsored and funded by your plan sponsor. Your plan sponsor has a
financial arrangement with Wellmark under which your plan sponsor is solely responsible for
claim payment amounts for covered services provided to you. Wellmark provides administrative
services and provider network access only and does not assume any financial risk or obligation
for claim payment amounts.

Group Effective Date: 1/1/2013

Plan Year: 01/01
Print Date: 4/29/2013
Coverage Code: ZY7 5AQ ZY8 5AR
Form Number: Wellmark IA Grp Version: 10/12

www.wellmark.com
Contents
About This Summary Plan Description ....................................................... 1
1. What You Pay .................................................................................... 3
Payment Summary........................................................................................................................... 3
Payment Details ............................................................................................................................... 7
2. At a Glance - Covered and Not Covered ............................................. 11
Medical Benefits Plan..................................................................................................................... 11
Prescription Drug Plan ................................................................................................................... 14
3. Details - Covered and Not Covered ................................................... 15
Medical Benefits Plan..................................................................................................................... 15
Prescription Drug Plan ................................................................................................................... 27
4. General Conditions of Coverage, Exclusions, and Limitations .......... 31
Conditions of Coverage.................................................................................................................. 31
General Exclusions ........................................................................................................................ 32
Benefit Limitations .......................................................................................................................... 33
5. Choosing a Provider ......................................................................... 35
Medical Benefits Plan..................................................................................................................... 35
Prescription Drug Plan ................................................................................................................... 38
6. Notification Requirements and Care Coordination .......................... 41
Medical Benefits Plan..................................................................................................................... 41
Prescription Drug Plan ................................................................................................................... 45
7. Factors Affecting What You Pay ....................................................... 47
Medical Benefits Plan..................................................................................................................... 47
Prescription Drug Plan ................................................................................................................... 49
Medical Benefits and Prescription Drug Plan ................................................................................ 52
8. Coverage Eligibility and Effective Date ............................................. 53
Who is Eligible................................................................................................................................ 53
Who Pays For Your Benefits .......................................................................................................... 53
Non-Tobacco Incentive .................................................................................................................. 54
When Coverage Begins ................................................................................................................. 54
Preexisting Condition Exclusion Period ......................................................................................... 55
Prior Creditable Coverage.............................................................................................................. 55
Qualified Medical Child Support Order .......................................................................................... 56
9. Coverage Changes and Termination ................................................. 59
Coverage Change Events .............................................................................................................. 59
Changing Plan Options .................................................................................................................. 60
Special Enrollment Events ............................................................................................................. 60
Late Enrollees ................................................................................................................................ 60
Requirement to Notify Plan Sponsor.............................................................................................. 61
The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) .......... 61
Coverage Termination.................................................................................................................... 62
Certificate of Creditable Coverage ................................................................................................. 63
Coverage Continuation .................................................................................................................. 64
Family and Medical Leave Act of 1993 .......................................................................................... 71
10. Claims.............................................................................................. 73
When to File a Claim ...................................................................................................................... 73
How to File a Claim ........................................................................................................................ 73
Notification of Decision................................................................................................................... 74
11. Coordination of Benefits .................................................................. 77
Other Coverage.............................................................................................................................. 77
Claim Filing .................................................................................................................................... 77
Rules of Coordination..................................................................................................................... 77
Coordination with Medicare ........................................................................................................... 79
12. Appeals ............................................................................................ 81
Right of Appeal............................................................................................................................... 81
How to Request an Internal Appeal ............................................................................................... 81
Where to Send Internal Appeal ...................................................................................................... 81
Review of Internal Appeal .............................................................................................................. 81
Decision on Internal Appeal ........................................................................................................... 82
Legal Action ................................................................................................................................... 82
13. Your Rights Under ERISA ................................................................ 83
14. General Provisions .......................................................................... 85
Contract .......................................................................................................................................... 85
Interpreting this Summary Plan Description................................................................................... 85
Authority to Terminate, Amend, or Modify ..................................................................................... 85
Authorized Group Health Plan Changes ........................................................................................ 85
Authorized Representative ............................................................................................................. 85
Release of Information ................................................................................................................... 86
Privacy of Information .................................................................................................................... 86
Member Health Support Services .................................................................................................. 86
Value Added or Innovative Benefits ............................................................................................... 87
Health Insurance Portability and Accountability Act of 1996 ......................................................... 87
Nonassignment .............................................................................................................................. 89
Governing Law ............................................................................................................................... 89
Legal Action ................................................................................................................................... 89
Medicaid Enrollment and Payments to Medicaid ........................................................................... 89
Subrogation .................................................................................................................................... 89
Workers’ Compensation ................................................................................................................. 91
Payment in Error ............................................................................................................................ 92
Notice ............................................................................................................................................. 92
Glossary .................................................................................................... 93
Index ........................................................................................................ 95
About This Summary Plan Description
Important Information
This summary plan description describes your rights and responsibilities under your group
health plan. You and your covered dependents have the right to request a copy of this summary
plan description, at no cost to you, by contacting your plan sponsor.
Please note: Your plan sponsor has the authority to terminate, amend, or modify the coverage
described in this summary plan description at any time. Any amendment or modification will be
in writing and will be as binding as this summary plan description. If your contract is
terminated, you may not receive benefits.
You should familiarize yourself with the entire summary plan description because it describes
your benefits, payment obligations, provider networks, claim processes, and other rights and
responsibilities.

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 summary plan description. (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 summary plan description. 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 or preexisting conditions (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.
Your coverage includes many services, treatments, supplies, devices, and drugs. Throughout the
summary plan description, 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.

Form Number: Wellmark IA Grp/AM_ 1011 1 ZY7 5AQ ZY8 5AR

 About This Summary Plan Description

Plan Description
Plan Name: Casey's General Stores, Inc., Employee Healthcare Benefit Plan
Plan Sponsor: Casey's General Stores, Inc.
Employer ID Number: 42-0935283
Plan Number: 501
When Plan Year Ends: December 31
Participants of Plan: See Coverage Eligibility and Effective Date later in this summary plan
description.
Plan Administrator and Agent Casey's General Stores, Inc.
for Service of Legal Process: One Convenience Blvd.
Ankeny, IA 50021
Phone Number: 515-965-6100
Service of legal process may be made upon the plan administrator and/or
agent.
How Plan Costs Are Funded: Employee pays part of employee and dependent costs.
Type of Plan: Group Health Plan
Type of Administration: Self-Funded
Benefits Administered by: Wellmark Blue Cross and Blue Shield of Iowa
1331 Grand Avenue
Des Moines, IA 50309-2901

If this plan is maintained by two or more employers, you may write to the plan administrator for
a complete list of the plan sponsors.

Grandfathered Health Plan Status

The Plan Administrator believes this Plan is a “grandfathered health plan” under the Patient
Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable
Care Act, a grandfathered health plan can preserve certain basic health coverage that was
already in effect when that law was enacted. Being a grandfathered health plan means that this
Plan may not include certain consumer protections of the Affordable Care Act that apply to
other plans, for example, the requirement for the provision of preventive health services without
any cost sharing. However, grandfathered health plans must comply with certain other
consumer protections in the Affordable Care Act, for example the elimination of lifetime limits
on benefits.
Questions regarding which protection apply and which protections do not apply to a
grandfathered health plan and what might cause a plan to change from grandfathered health
plan status can be directed to the plan administrator at:
One Convenience Blvd.
Ankeny, IA 50021
You may also contact the Employee Benefits Security Administration, U.S. Department of Labor
at 866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing
which protections do and do not apply to grandfathered health plans.

ZY7 5AQ ZY8 5AR 2 Form Number: Wellmark IA Grp/AM_ 1011

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 summary plan description, especially the Factors
Affecting What You Pay and Choosing a Provider sections.

Medical Benefits Plan

Health Plan Basics
You can receive care from any provider you choose. When you choose a provider who
participates in the PPO network, you may reduce your out-of-pocket expenses. To determine if a
provider participates with this medical benefits plan, ask your provider, visit our Web site at
www.wellmark.com, or www.bcbs.com, refer to your provider directory (a separate document
that's available, without charge), or call 800-810-BLUE.

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.

Medical Covered Benefits

Premium Plan Standard Plan
When you receive these services, you pay:
Out-of- Out-of-
In-Network In-Network
Health Plan Basics Benefit
Network
Benefit
Network
Benefit Benefit
Benefit Period Deductible
Amount you pay in a calendar year before
certain benefits are available. $300 Single $500 Single $500 Single $1,000 Single
In-Network and Out-of-Network Deductibles $600 Family $1,000 Family $1,000 Family $2,000 Family
apply to each other.

Out-of-Pocket Maximum (OPM)

Maximum amount you pay for covered
services each calendar year.
In-Network and Out-of-Network OPMs apply
to each other.
Deductible and coinsurance apply to OPM.
Once your OPM is satisfied, most services $2,000 Single $3,000 Single $3,000 Single $5,000 Single
are covered in-full through the end of the $4,000 Family $6,000 Family $6,000 Family $10,000 Family
calendar year.
The following amounts DO NOT apply
toward out of pocket maximum:
 Co-payments for certain services
 Non-covered services
 Infertility services

Form Number: Wellmark IA Grp/WYP_ 1012 3 ZY7 5AQ ZY8 5AR

 What You Pay

Medical Covered Benefits

Premium Plan Standard Plan
When you receive these services, you pay:

Out-of- Out-of-
In-Network In-Network
Health Plan Basics Network Network
Benefit Benefit
Benefit Benefit
Coinsurance
Percentage of medical expenses you pay
after the deductible is met (unless otherwise 10% 30% 20%
40% coinsurance
noted), until you reach your out-of-pocket coinsurance coinsurance coinsurance
maximum.

Office Services/Independent Lab 30%

40% coinsurance
Amount you pay at the time you receive $20 copayment coinsurance $25 copayment
after deductible
certain office-based services. after deductible
30%
Allergy Injections, Including Serum 40% coinsurance
$20 copayment coinsurance $25 copayment
Office after deductible
after deductible
Specialty Drugs
Administered in an office or outpatient
hospital facility.
$85 copayment $85 copayment
(Call Wellmark customer service for a listing
of drugs eligible for this benefit or visit
www.wellmark.com)

Preventive Care Services

 Physical exam (one per benefit period)
 Gynecological exam
 Immunizations 30%
 X-ray/labs coinsurance 40% coinsurance
 Mammogram (one per benefit period) $20 copayment $25 copayment
after after deductible**
 Pap smears deductible**
 Prostate screening
 Well-child care
**Deductible waived for well-child care.

Outpatient Mammograms, 30%

40% coinsurance
Colonoscopies and Sigmoidoscopies $20 copayment coinsurance $25 copayment
after deductible
after deductible
Chiropractic Care Office Services 10% 30% 20%
Limited to a maximum benefit of $500 per 40% coinsurance
coinsurance coinsurance coinsurance
year after deductible
after deductible after deductible after deductible
Maternity Care 10% 30% 20%
Physician services 40% coinsurance
 coinsurance coinsurance coinsurance
Facility services after deductible
 after deductible after deductible after deductible
Dental Treatment 10% 30% 20%
40% coinsurance
For accidental injury only. coinsurance coinsurance coinsurance
after deductible
after deductible after deductible after deductible
Physician Services 10% 30% 20%
Inpatient facility care 40% coinsurance
 coinsurance coinsurance coinsurance
Outpatient facility care after deductible
 after deductible after deductible after deductible

ZY7 5AQ ZY8 5AR 4 Form Number: Wellmark IA Grp/WYP_ 1012

 What You Pay

Medical Covered Benefits

Premium Plan Standard Plan
When you receive these services, you pay:
Out-of- Out-of-
In-Network In-Network
Health Plan Basics Network Network
Benefit Benefit
Benefit Benefit
Facility Services
10% 30% 20% 40%
 Inpatient hospital coinsurance coinsurance coinsurance coinsurance
 Outpatient hospital after deductible after deductible after deductible after deductible

Nursing Facility 10% 30% 20% 40%

Limited to 90 days per benefit period coinsurance coinsurance coinsurance coinsurance
after deductible after deductible after deductible after deductible
30% 40%
Surgery Services coinsurance $25 copayment coinsurance
$20 copayment
 In a Physician’s Clinic/Office after deductible 20% after deductible
10%
 Inpatient & Outpatient Hospital 30% coinsurance 40%
coinsurance
 Ambulatory Facility coinsurance after deductible coinsurance
after deductible
after deductible after deductible
10% 30% 20% 40%
Ambulance coinsurance coinsurance coinsurance coinsurance
after deductible after deductible after deductible after deductible
Emergency Room (if admitted, see
Facility Services)
 Facility services $75 copayment $75 copayment $100 copayment $100 copayment
 Physician services followed by 10% followed by 30% followed by 20% followed by 40%
coinsurance coinsurance*** coinsurance coinsurance***
***Processed at PPO level if true
emergency

10% 30% 20% 40%

Home/Durable Medical Equipment coinsurance coinsurance coinsurance coinsurance
after deductible after deductible after deductible after deductible
10% 30% 20% 40%
Home Health Care coinsurance coinsurance coinsurance coinsurance
after deductible after deductible after deductible after deductible
Hospice Services 10% 30% 20% 40%
(Hospice respite limited to 15 days coinsurance coinsurance coinsurance coinsurance
inpatient/15 days outpatient) after deductible after deductible after deductible after deductible

Lifetime Benefits Maximum

The maximum amount each covered family Unlimited
member is eligible to receive under this plan
for covered services in his/her lifetime.

Annual Benefits Maximum

The maximum amount each covered family $2,000,000
member is eligible to receive under this plan
for covered services per calendar year.

Lifetime Maximum for Infertility Services $2,000 Not Covered

Form Number: Wellmark IA Grp/WYP_ 1012 5 ZY7 5AQ ZY8 5AR

 What You Pay

Medical Covered Benefits

Premium Plan Standard Plan
When you receive these services, you pay:

Lifetime Maximum for Weight-loss

surgery One Surgery per lifetime
Includes follow up care and complications

Pharmacy Covered Benefits

Premium Pharmacy Plan Standard Pharmacy Plan
When you receive these services, you pay:

Individual Deductible (waived for Generic

$50 $100
drugs)

Family Deductible (waived for Generic

$150 $300
drugs)

Generic (Tier 1) $10 $15

Specially Selected Brand Name Drugs (Tier

$20 $25
2)

All Other Brand-Name Drugs (Tier 3) $45 $50

Vaccinations at the Pharmacy $20 $25

Specialty Self-Administered Drugs
For a listing of these drugs, call Wellmark
$85 $85
customer service or visit
www.wellmark.com
Drug Quantities
30 days – retail pharmacy, brand  One copay for each 30 day supply – retail
90 days – retail pharmacy, generic  Two copays for each 90 day supply – mail
90 days – mail order  If you purchase a Tier 2 or Tier 3 drug when an A-rated generic drug is
available, you are responsible for your deductible and/or copayment
amount plus any difference in price between the billed charge for the
generic drug and the billed charge for the brand-name drug. You are
responsible for this difference even if your provider has specified that
you must take the brand name drug (DAW).

See the Wellmark Blue Rx Value Plus Drug List at www.wellmark.com for more information.

Federal regulations limit the quantity that may be dispensed for certain medications. If your
prescription is so regulated, it may not be available in the amount(s) indicated.

Covered
 Most prescription drugs that bear the legend, “Caution, Federal Law prohibits dispensing
without a prescription”
 Drugs dispensed by a pharmacist from a licensed retail pharmacy
 Prescription drugs that are prescribed by a practitioner legally authorized to prescribe
 Insulin and these insulin supplies: needles, syringes, test strips, and lancets
 Oral contraceptives

ZY7 5AQ ZY8 5AR 6 Form Number: Wellmark IA Grp/WYP_ 1012

 What You Pay

 Prenatal vitamins
 Smoking cessation drugs are covered
 Weight loss drugs, with prior authorization

Not Covered
 Cosmetic drugs
 Drugs determined to be abused or otherwise misused by you
 Drugs that require a prescription by state law but not federal law
 Growth hormones
 Immunization agents
 Infertility drugs
 Investigational drugs
 Irrigation solutions and supplies
 Nutritional supplements
 Over-the-counter products including nutritional dietary supplements
 Self-help or self-cure programs
 Therapeutic devices or medical appliances

Payment Details
Medical Benefits Plan

Deductible
This is a fixed dollar amount you pay for covered services in a benefit year before medical
benefits become available.
The family deductible amount is reached from amounts accumulated on behalf of any
combination of family members.
Deductible amounts you pay for PPO or non-PPO provider services apply toward meeting both
the PPO and the non-PPO deductibles. The maximum deductible amount you pay is the non-
PPO deductible.
Once you meet the deductible, then coinsurance applies.
Deductible amounts are waived for some services.

Copayment
This is a fixed dollar amount that you pay each time you receive certain covered services.
Emergency Room Copayment.
The emergency room copayment:
 applies to emergency room services.
 is taken once per facility per date of service.
 is waived if you are admitted as an inpatient of a facility immediately following emergency
room services.

Form Number: Wellmark IA Grp/WYP_ 1012 7 ZY7 5AQ ZY8 5AR

 What You Pay

Office Visit Copayment.

The office visit copayment:
 applies to covered office services received from PPO practitioners. Laboratory services
received from a PPO independent lab are subject to a separate office visit copayment.
 is taken once per practitioner per date of service.

The office visit copayment does not apply to:

 prescription contraceptive medical devices, implanted contraceptives, and injected
contraceptives.
 services received from chiropractors.

These services are subject to deductible and coinsurance and not this copayment.
Other Copayment.
The other copayment:
 applies to outpatient colonoscopies, sigmoidoscopies, and mammograms received from PPO
providers.
 is taken once per provider per date of service.

Coinsurance
Coinsurance is an amount you pay for certain covered services. Coinsurance is calculated by
multiplying the fixed percentage(s) shown earlier in this section times Wellmark’s payment
arrangement amount. Payment arrangements may differ depending on the contracting status of
the provider and/or the state where you receive services. For details, see How Coinsurance is
Calculated, page 47. Coinsurance amounts apply after you meet the deductible and any
applicable copayments.
Coinsurance amounts are waived for some services.

Out-of-Pocket Maximum
The out-of-pocket maximum is the maximum amount you pay, out of your pocket, for most
covered services in a benefit year. Many amounts you pay for covered services during a benefit
year accumulate toward the out-of-pocket maximum. These amounts include:
 Deductible.
 Coinsurance.

The family out-of-pocket maximum is reached from applicable amounts paid on behalf of any
combination of family members.
Out-of-pocket maximum amounts you pay for PPO or non-PPO provider services apply toward
meeting both the PPO and non-PPO out-of-pocket maximums.
However, certain amounts do not apply toward your out-of-pocket maximum.
 Amounts representing any general exclusions and conditions. See General Conditions of
Coverage, Exclusions, and Limitations, page 31.
 Copayments.

These amounts continue even after you have met your out-of-pocket maximum.

ZY7 5AQ ZY8 5AR 8 Form Number: Wellmark IA Grp/WYP_ 1012

 What You Pay

Lifetime Benefits Maximum

This is the maximum benefit that each member is eligible to receive for certain covered services
in his or her lifetime.
Lifetime benefits maximums are accumulated from benefits under this medical benefits plan
(which includes the Premium Plan, the Standard Plan, and/or the High Deductible Health Plan)
and prior medical benefits plans sponsored by your plan sponsor.

Benefit Year Maximum

This is the combined maximum benefit amount that each member is eligible to receive for
certain covered services in a benefit year.
The benefit year maximum is accumulated from claim payment amounts under this medical
benefits plan (which includes the Premium Plan, the Standard Plan, and/or the High Deductible
Health Plan).
The benefit year maximum applies to all of the following services combined:
 Ambulatory patient services.
 Emergency services.
 Hospitalization.
 Laboratory services.
 Maternity and newborn care.
 Mental health and substance abuse disorder services, including behavioral health treatment.
 Pediatric services, including oral and vision care.
 Prescription drugs covered under this medical benefits plan. Claims for prescription drugs
covered under your prescription drug plan do not count toward this maximum.
 Preventive and wellness services and chronic disease management.
 Rehabilitative and habilitative services and devices.

Specialty Rx

Copayment
Copayment is a fixed dollar amount you pay
each time a prescription is filled or refilled
for a specialty drug.

Prescription Drug Plan

Once you meet the deductible, then the
Deductible copayment applies.
Deductible is the fixed dollar amount you The deductible is waived for the following:
pay for covered drugs in a benefit year
before prescription drug plan benefits  Generic drugs.
become available.  Well-child care immunizations.
The family deductible is reached from
amounts accumulated on behalf of any
combination of family members.

Form Number: Wellmark IA Grp/WYP_ 1012 9 ZY7 5AQ ZY8 5AR

 What You Pay

Copayment
Copayment is a fixed dollar amount you pay
each time a covered prescription is filled or
refilled. Copayment amounts apply after you
meet the deductible for the benefit year.
You pay the entire cost if you purchase a
drug that is not on the Wellmark Drug List.

ZY7 5AQ ZY8 5AR 10 Form Number: Wellmark IA Grp/WYP_ 1012

2. At a Glance - Covered and Not Covered
Medical Benefits Plan
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 summary plan description. 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 summary plan description. 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.
Service Maximum. This column lists maximum benefit amounts that each member is eligible
to receive. Service 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 plan sponsor.
Please note: Service maximums accumulate for medical and prescription drug benefits
separately.
Not Covered
See Page
Covered

Category Service Maximum

Acupuncture Treatment  15
Allergy Testing and Treatment  15
Ambulance Services  15
Anesthesia  15
Blood and Blood Administration  15
Chemical Dependency Treatment   15
Chemotherapy and Radiation Therapy  15
Contraceptives   15
Cosmetic Services  16
Counseling and Education Services  16
Dental Treatment for Accidental Injury  16

Form Number: Wellmark IA Grp/AGC_ 1012 11 ZY7 5AQ ZY8 5AR

 At A Glance – Covered and Not Covered

Not Covered
See Page
Covered
Category Service Maximum

Dialysis  17
Education Services for Diabetes   17
10 hours of outpatient diabetes self-management training
provided within a 12-month period, plus follow-up training of
up to two hours annually.
Emergency Services  17
Fertility and Infertility Services   17
Premium Plan: $2,000 per lifetime for covered services and
supplies related to infertility treatment.
Standard Plan: Infertility treatment is not covered.
Genetic Testing  18
Hearing Services (related to an illness or  18
injury)
Home Health Services  18
Home/Durable Medical Equipment  19
Two pairs of compression garments per benefit year.
Hospice Services   19
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  20
90 days per benefit year of skilled nursing services in a
hospital or nursing facility.
Illness or Injury Services  20
Inhalation Therapy  20
Maternity Services  21
Medical and Surgical Supplies  21
Mental Health Services   21
Morbid Obesity Treatment   22
  One weight reduction surgery per lifetime.
Motor Vehicles   22
Musculoskeletal Treatment   22
Nonmedical Services   22
Occupational Therapy  23
Orthotics   23

ZY7 5AQ ZY8 5AR 12 Form Number: Wellmark IA Grp/AGC_ 1012

 At A Glance – Covered and Not Covered

Not Covered
See Page
Covered
Category Service Maximum

Physical Therapy  23
Physicians and Practitioners 23
Advanced Registered Nurse   23
Practitioners
Audiologists  23
Chiropractors   23
$500 per benefit year, including x-ray services.
Doctors of Osteopathy  23
Licensed Independent Social Workers  23
Medical Doctors  23
Occupational Therapists  23
Optometrists  23
Oral Surgeons  23
Physical Therapists  23
Physician Assistants   23
Podiatrists  23
Psychologists  23
Speech Pathologists  23
Prescription Drugs   24
Preventive Care   25
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  25
Reconstructive Surgery  25
Self Help Programs  26
Sleep Apnea Treatment  26
Speech Therapy  26
Surgery  26
Temporomandibular Joint Disorder   26
(TMD)
 Premium Plan: $3,000 per lifetime for treatment.
Standard Plan: Treatment of temporomandibular joint
disorder is not covered.
Transplants   26
Travel or Lodging Costs  27
$10,000 per transplant for lodging and meals when related to
a transplant received at a Blue Distinction Center for
Transplant.

Form Number: Wellmark IA Grp/AGC_ 1012 13 ZY7 5AQ ZY8 5AR

 At A Glance – Covered and Not Covered

Not Covered
See Page
Covered
Category Service Maximum

Vision Services (related to an illness or  27

injury)
Wigs or Hairpieces  27
$400 per lifetime.
X-ray and Laboratory Services  27

Prescription Drug Plan

Please note: To determine if a drug is covered, you must consult the Wellmark Blue Rx Value
Plus Drug List. You are covered for drugs listed on the Wellmark Blue Rx Value Plus Drug List.
If a drug is not on the Wellmark Blue Rx Value Plus 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.

ZY7 5AQ ZY8 5AR 14 Form Number: Wellmark IA Grp/AGC_ 1012

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 summary plan description. Also see the section
General Conditions of Coverage, Exclusions, and Limitations, page 31. If a service or supply is
not specifically listed, do not assume it is covered.

Medical Benefits Plan

Acupuncture Treatment Blood and Blood

Not Covered: Acupuncture and
Administration
acupressure treatment. Covered: Blood and blood administration,
including blood derivatives, and blood
Allergy Testing and components.
Treatment
Chemical Dependency
Covered.
Treatment
Ambulance Services Covered: Treatment for a condition with
physical or psychological symptoms
Covered: Professional air and ground
produced by the habitual use of certain
ambulance transportation to a hospital or
drugs as described in the most current
nursing facility in the surrounding area
Diagnostic and Statistical Manual of
where your ambulance transportation
Mental Disorders.
originates.
Not Covered:
All of the following are required to qualify
for benefits:  Residential facility services.
 No other method of transportation is See Also:
appropriate.
Hospitals and Facilities later in this section.
 The services required to treat your
illness or injury are not available in the
facility where you are currently receiving
Chemotherapy and Radiation
care if you are an inpatient at a facility. Therapy
 You are transported to the nearest Covered: Use of chemical agents or
hospital or nursing facility with radiation to treat or control a serious illness.
adequate facilities to treat your medical
condition. Contraceptives
Covered: The following conception
Anesthesia prevention, as approved by the U.S. Food
Covered: Anesthesia and the and Drug Administration:
administration of anesthesia.  Contraceptive medical devices, such as
Not Covered: Local or topical anesthesia intrauterine devices and diaphragms.
billed separately from related surgical or  Implanted contraceptives.
medical procedures.  Injected contraceptives.

Form Number: Wellmark IA Grp/DE_ 1012 15 ZY7 5AQ ZY8 5AR

 Details – Covered and Not Covered

Not Covered (these are covered under  Anesthesia (general) and hospital or
your prescription drug plan). See the ambulatory surgical facility services
Wellmark Drug List at www.wellmark.com related to covered dental services if:
or call the Customer Service number on  You are under age 14 and, based on a
your ID card and request a copy of the Drug determination by a licensed dentist
List: and your treating physician, you
 Contraceptive drugs and contraceptive have a dental or developmental
drug delivery devices, such as insertable condition for which patient
rings and patches. management in the dental office has
been ineffective and requires dental
Cosmetic Services treatment in a hospital or
ambulatory surgical facility; or
Not Covered: Cosmetic services, supplies,
 Based on a determination by a
or drugs if provided primarily to improve
physical appearance. A service, supply or licensed dentist and your treating
drug that results in an incidental physician, you have one or more
improvement in appearance may be covered medical conditions that would create
if it is provided primarily to restore function significant or undue medical risk in
lost or impaired as the result of an illness, the course of delivery of any
accidental injury, or a birth defect. You are necessary dental treatment or
also not covered for treatment for any surgery if not rendered in a hospital
complications resulting from a noncovered or ambulatory surgical facility.
cosmetic procedure.  Impacted teeth removal (surgical) as an
inpatient or outpatient of a facility only
See Also: when you have a medical condition
Reconstructive Surgery later in this section. (such as hemophilia) that requires
hospitalization.
Counseling and Education  Facial bone fracture reduction.
Services  Incisions of accessory sinus, mouth,
Not Covered: salivary glands, or ducts.
 Jaw dislocation manipulation.
 Bereavement counseling or services
 Orthodontic services required for
(including volunteers or clergy), family
surgical management of cleft palate.
counseling or training services, and
marriage counseling or training services.  Treatment of abnormal changes in the
mouth due to injury or disease.
 Education or educational therapy other
than covered education for self- Not Covered:
management of diabetes.
 General dentistry including, but not
See Also: limited to, diagnostic and preventive
services, restorative services, endodontic
Genetic Testing later in this section.
services, periodontal services, indirect
Education Services for Diabetes later in this fabrications, dentures and bridges, and
section. orthodontic services unrelated to
Mental Health Services later in this section. accidental injuries or surgical
management of cleft palate.
Dental Services  Injuries associated with or resulting
from the act of chewing.
Covered:
 Maxillary or mandibular tooth implants
 Dental treatment for accidental injuries. (osseointegration) unrelated to

ZY7 5AQ ZY8 5AR 16 Form Number: Wellmark IA Grp/DE_ 1012

 Details – Covered and Not Covered

accidental injuries or abnormal changes knowledge of health and medicine, could

in the mouth due to injury or disease. reasonably expect absence of immediate
medical attention to result in:
Dialysis  Placing the health of the individual or,
Covered: Removal of toxic substances with respect to a pregnant woman, the
from the blood when the kidneys are unable health of the woman and her unborn
to do so when provided as an inpatient in a child, in serious jeopardy; or
hospital setting or as an outpatient in a  Serious impairment to bodily function;
Medicare-approved dialysis center. or
 Serious dysfunction of any bodily organ
Education Services for or part.
Diabetes
Covered: Inpatient and outpatient training In an emergency situation, if you cannot
and education for the self-management of reasonably reach a PPO provider, covered
all types of diabetes mellitus. services will be reimbursed as though they
were received from a PPO provider.
All covered training or education must be However, because we do not have contracts
prescribed by a licensed physician. with nonparticipating providers and they
Outpatient training or education must be may not accept our payment arrangements,
provided by a state-certified program. you are responsible for any difference
The state-certified diabetic education between the amount charged and our
program helps any type of diabetic and his amount paid for a covered service.
or her family understand the diabetes See Also:
disease process and the daily management
of diabetes. Nonparticipating providers, page 48.

You are also covered for nutrition education Fertility and Infertility
to improve your understanding of your
metabolic nutritional condition and provide
Services
you with information to manage your
Premium Plan
nutritional requirements. Nutrition
education is appropriate for, but not limited Covered:
to:  Fertility prevention, such as tubal
 Glucose intolerance. ligation (or its equivalent) or vasectomy
(initial surgery only).
 High blood pressure.
 Infertility testing and treatment for
 Lactose intolerance.
infertile members including in vitro
 Morbid obesity. fertilization, gamete intrafallopian
Service Maximum: transfer (GIFT), and pronuclear stage
transfer (PROST).
 10 hours of outpatient diabetes self-
management training provided within a Service Maximum:
12-month period, plus follow-up  $2,000 per lifetime for covered services
training of up to two hours annually. and supplies related to infertility
treatment.
Emergency Services
Covered: When treatment is for a medical Not Covered:
condition manifested by acute symptoms of  Infertility treatment if the infertility is
sufficient severity, including pain, that a the result of voluntary sterilization.
prudent layperson, with an average

Form Number: Wellmark IA Grp/DE_ 1012 17 ZY7 5AQ ZY8 5AR

 Details – Covered and Not Covered

 The collection or purchase of donor Hearing Services

semen (sperm) or oocytes (eggs) when
Covered:
performed in connection with fertility or
infertility procedures or for any other  Hearing examinations, but only to test
reason or service; freezing of sperm, or treat hearing loss related to an illness
oocytes, or embryos; surrogate parent or injury.
services.
Not Covered:
 Reversal of a tubal ligation (or its
equivalent) or vasectomy.  Hearing aids.
 Routine hearing examinations.
Standard Plan
Covered: Home Health Services
 Fertility prevention, such as tubal Covered: All of the following requirements
ligation (or its equivalent) or vasectomy must be met in order for home health
(initial surgery only). services to be covered:
 You require a medically necessary
Not Covered:
skilled service such as skilled nursing,
 Infertility treatment if the infertility is physical therapy, or speech therapy.
the result of voluntary sterilization.  Services are received from an agency
 The collection or purchase of donor accredited by the Joint Commission for
semen (sperm) or oocytes (eggs) when Accreditation of Health Care
performed in connection with fertility or Organizations (JCAHO) and/or a
infertility procedures or for any other Medicare-certified agency.
reason or service; freezing of sperm,  Services are prescribed by a physician
oocytes, or embryos; surrogate parent and approved by our case manager for
services. the treatment of illness or injury.
 Infertility diagnosis and treatment.  Services are not more costly than
 Reversal of a tubal ligation (or its alternative services that would be
equivalent) or vasectomy. effective for diagnosis and treatment of
your condition.
Genetic Testing  The care is prescribed by a physician
Covered: Genetic molecular testing and approved by a Wellmark case
(specific gene identification) and related manager.
counseling are covered when both of the
following requirements are met: The following are covered services and
supplies:
 You are an appropriate candidate for a
test under medically recognized Home Health Aide Services—when
standards (for example, family provided in conjunction with a
background, past diagnosis, etc.). medically necessary skilled service also
received in the home.
 The outcome of the test is expected to
determine a covered course of treatment Home Skilled Nursing. Treatment
or prevention and is not merely must be given by a registered nurse
informational. (R.N.) or licensed practical nurse
(L.P.N.) from an agency accredited by
the Joint Commission for Accreditation
of Health Care Organizations (JCAHO)
or a Medicare-certified agency. Home
skilled nursing is intended to provide a

ZY7 5AQ ZY8 5AR 18 Form Number: Wellmark IA Grp/DE_ 1012

 Details – Covered and Not Covered

safe transition from other levels of care See Also:

when medically necessary, to provide
Case Management, page 45.
teaching to caregivers for ongoing care,
or to provide short-term treatments that
can be safely administered in the home
Home/Durable Medical
setting. The daily benefit for home Equipment
skilled nursing services will not exceed Covered: Equipment that meets all of the
Wellmark’s daily maximum allowable following requirements:
fee for care in a skilled nursing facility.  Durable enough to withstand repeated
Home skilled nursing will be use.
coordinated by a case manager.
 Primarily and customarily
Custodial care is not included in this
manufactured to serve a medical
benefit.
purpose.
Inhalation Therapy.  Used to serve a medical purpose.
Medical Equipment. In addition, we determine whether to pay
Medical Social Services. the rental amount or the purchase price
amount for an item, and we determine the
Medical Supplies.
length of any rental term. Benefits will never
Occupational Therapy—but only for exceed the lesser of the amount charged or
services to treat the upper extremities, the maximum allowable fee.
which means the arms from the
Service Maximum:
shoulders to the fingers. You are not
covered for occupational therapy  Two pairs of compression garments
supplies. per benefit year.
Oxygen and Equipment for its See Also:
administration.
Medical and Surgical Supplies later in this
Parenteral and Enteral Nutrition. section.
Physical Therapy. Orthotics later in this section.
Prescription Drugs and Medicines Personal Convenience Items in the section
administered in the vein or muscle. General Conditions of Coverage,
Prosthetic Devices and Braces. Exclusions, and Limitations, page 33.

Speech Therapy. Prosthetic Devices later in this section.

Not Covered: Custodial home care Hospice Services

services and supplies, which help you with
Covered: Care (generally in a home
your daily living activities. This type of care
setting) for patients who are terminally ill
does not require the continuing attention
and who have a life expectancy of six
and assistance of licensed medical or
months or less. Hospice care covers the
trained paramedical personnel. Some
same services as described under Home
examples of custodial care are assistance in
Health Services, as well as hospice respite
walking and getting in and out of bed; aid in
care from a facility approved by Medicare or
bathing, dressing, feeding, and other forms
by the Joint Commission for Accreditation
of assistance with normal bodily functions;
of Health Care Organizations (JCAHO).
preparation of special diets; and supervision
of medication that can usually be self- Hospice respite care offers rest and relief
administered. You are also not covered for help for the family caring for a terminally ill
sanitaria care or rest cures. patient. Inpatient respite care can take place

Form Number: Wellmark IA Grp/DE_ 1012 19 ZY7 5AQ ZY8 5AR

 Details – Covered and Not Covered

in a nursing home, nursing facility, or Service Maximum:

hospital.
 90 days per benefit year for skilled
Service Maximum: nursing services in a hospital or nursing
facility.
 15 days per lifetime for inpatient
hospice respite care. Not Covered:
 15 days per lifetime for outpatient
 Residential Treatment Facility. This type
hospice respite care.
of facility provides treatment for severe,
 Not more than five days of hospice persistent, or chronic mental health
respite care at a time. conditions or chemical dependency that
meets all of the following criteria:
Hospitals and Facilities  Treatment is provided in a 24-hour
Covered: Hospitals and other facilities that residential setting.
meet standards of licensing, accreditation or  Treatment involves therapeutic
certification. Following are some recognized intervention and specialized
facilities: programming with a high degree of
Ambulatory Surgical Facility. This structure and supervision.
type of facility provides surgical services  Treatment includes training in basic
on an outpatient basis for patients who skills such as social skills and
do not need to occupy an inpatient activities of daily living.
hospital bed.  Treatment does not require daily

Chemical Dependency Treatment supervision of a physician.

Facility. This type of facility provides  Psychiatric Medical Institution for
treatment of chemical dependency and Children.
must be licensed and approved by
Wellmark. Illness or Injury Services
Community Mental Health Center. Covered: Services or supplies used to treat
This type of facility provides outpatient any bodily disorder, bodily injury, disease,
treatment of mental health conditions or mental health condition unless
and must be licensed and approved by specifically addressed elsewhere in this
Wellmark. section. This includes pregnancy and
complications of pregnancy.
Hospital. This type of facility provides
for the diagnosis, treatment, or care of Treatment may be received from an
injured or sick persons on an inpatient approved provider in any of the following
and outpatient basis. The facility must settings:
be licensed as a hospital under  Home.
applicable law.  Inpatient (such as a hospital or nursing
Nursing Facility. This type of facility facility).
provides continuous skilled nursing  Office (such as a doctor’s office).
services as ordered and certified by your  Outpatient.
attending physician on an inpatient
basis. A registered nurse (R.N.) must Inhalation Therapy
supervise services and supplies on a 24-
Covered: Respiratory or breathing
hour basis. The facility must be licensed
treatments to help restore or improve
as a nursing facility under applicable
breathing function.
law.

ZY7 5AQ ZY8 5AR 20 Form Number: Wellmark IA Grp/DE_ 1012

 Details – Covered and Not Covered

Maternity Services are receiving care. To determine if a

provider has a contractual arrangement
Covered: Prenatal and postnatal care,
with a particular Blue Plan or with
delivery, including complications of
Wellmark, call the Customer Service
pregnancy. A complication of pregnancy
number on your ID card or visit our website,
refers to a cesarean section that was not
www.wellmark.com.
planned, an ectopic pregnancy that is
terminated, or a spontaneous termination of See Also:
pregnancy that occurs during a period of Coverage Change Events, page 59.
gestation in which a viable birth is not
possible. Complications of pregnancy also
Medical and Surgical
include conditions requiring inpatient
hospital admission (when pregnancy is not Supplies
terminated) whose diagnoses are distinct Covered: Medical supplies and devices
from pregnancy but are adversely affected such as:
by pregnancy or are caused by pregnancy.  Dressings and casts.
Please note: You must notify us or your  Oxygen and equipment needed to
plan sponsor if you enter into an administer the oxygen.
arrangement to provide surrogate parent  Diabetic equipment and supplies
services: Contact your plan sponsor or call including insulin syringes purchased
the Customer Service number on your ID from a covered home/durable medical
card. equipment provider.
In accordance with federal or applicable Not Covered:
state law, maternity services include a
minimum of:  Elastic stockings or bandages including
trusses, lumbar braces, garter belts, and
 48 hours of inpatient care (in addition to similar items that can be purchased
the day of delivery care) following a without a prescription.
vaginal delivery, or
 96 hours of inpatient care (in addition to See Also:
the day of delivery) following a cesarean Home/Durable Medical Equipment earlier
section. in this section.
A practitioner is not required to seek Orthotics later in this section.
Wellmark’s review in order to prescribe a
Personal Convenience Items in the section
length of stay of less than 48 or 96 hours.
General Conditions of Coverage,
The attending practitioner, in consultation
Exclusions, and Limitations, page 33.
with the mother, may discharge the mother
or newborn prior to 48 or 96 hours, as Prosthetic Devices later in this section.
applicable.
If the inpatient hospital stay is shorter,
Mental Health Services
coverage includes a follow-up postpartum Covered: Treatment for certain
home visit by a registered nurse (R.N.). This psychiatric, psychological, or emotional
nurse must be from a home health agency conditions as an inpatient or outpatient.
under contract with Wellmark or employed Recognized facilities for mental health
by the delivering physician. If you are services include licensed and accredited
receiving care outside Iowa or South community mental health centers that
Dakota, the nurse should be from a home provide mental health services on an
health agency under a contractual outpatient basis.
arrangement with the Blue Plan where you

Form Number: Wellmark IA Grp/DE_ 1012 21 ZY7 5AQ ZY8 5AR

 Details – Covered and Not Covered

Coverage includes diagnosis and treatment covered. Prior approval for weight reduction
of these biologically based mental illnesses: surgery is required. For information on how
to submit a prior approval request, refer to
 Schizophrenia.
Prior Approval in the Notification
 Bipolar disorders.
Requirements and Care Coordination
 Major depressive disorders. section of this summary plan description, or
 Schizo-affective disorders. call the Customer Service number on your
 Obsessive-compulsive disorders. ID card.
 Pervasive developmental disorders. Service Maximum:
 Autistic disorders.
 One weight reduction surgery per
To qualify for mental health treatment lifetime.
benefits, the following requirements must
Not Covered:
be met:
 Weight reduction programs or supplies
 The disorder is listed only as a mental
(including dietary supplements, foods,
health condition in the most current
equipment, lab testing, examinations,
“International Classification of Diseases,
and prescription drugs), whether or not
Ninth Revision, Clinical Modification”
weight reduction is medically
(ICD-9-CM) and not dually listed
appropriate.
elsewhere in the ICD-9-CM.
 The disorder is not a chemical See Also:
dependency condition.
Weight Reduction Drugs later in this
Not Covered: section.
 Certain disorders related to early
childhood, such as academic
Motor Vehicles
underachievement disorder. Not Covered: Purchase or rental of motor
vehicles such as cars or vans. You are also
 Communication disorders, such as
not covered for equipment or costs
stuttering and stammering.
associated with converting a motor vehicle
 Impulse control disorders, such as to accommodate a disability.
pathological gambling.
 Nonpervasive developmental and Musculoskeletal Treatment
learning disorders.
Covered: Outpatient nonsurgical
 Sensitivity, shyness, and social treatment of ailments related to the
withdrawal disorders. musculoskeletal system, such as
 Sexual identification or gender manipulations or related procedures to treat
disorders. musculoskeletal injury or disease.
 Residential facility services.
Not Covered: Massage therapy.
See Also:
Nonmedical Services
Hospitals and Facilities earlier in this
section. Not Covered: Such services as telephone
consultations, charges for failure to keep
scheduled appointments, charges for
Morbid Obesity Treatment
completion of any form, charges for medical
Covered: Weight reduction surgery information, recreational therapy, and any
provided the surgery is medically necessary services or supplies that are nonmedical.
for your condition. Not all procedures
classified as weight reduction surgery are

ZY7 5AQ ZY8 5AR 22 Form Number: Wellmark IA Grp/DE_ 1012

 Details – Covered and Not Covered

Occupational Therapy Physicians and Practitioners

Covered: Services are covered, but only Covered: Most services provided by
those services to treat the upper extremities, practitioners that are recognized by us and
which means the arms from the shoulders to meet standards of licensing, accreditation or
the fingers. certification. Following are some recognized
physicians and practitioners:
Not Covered:
Advanced Registered Nurse
 Occupational therapy supplies.
Practitioners (ARNP). An ARNP is a
 Occupational therapy provided as an
registered nurse with advanced training
inpatient in the absence of a separate
in a specialty area who is registered with
medical condition that requires
the Iowa Board of Nursing to practice in
hospitalization.
an advanced role with a specialty
designation of certified clinical nurse
Orthotics specialist, certified nurse midwife,
Not Covered: Orthotic foot devices such as certified nurse practitioner, or certified
arch supports or in-shoe supports, registered nurse anesthetist.
orthopedic shoes, elastic supports, or
examinations to prescribe or fit such Audiologists.
devices. Chiropractors.
See Also: Service Maximum:
Home/Durable Medical Equipment earlier  $500 per benefit year for
in this section. chiropractic services, including
Personal Convenience Items in the section x-ray services.
General Conditions of Coverage, Doctors of Osteopathy (D.O.).
Exclusions, and Limitations, page 33.
Licensed Independent Social
Prosthetic Devices later in this section. Workers.

Physical Therapy Medical Doctors (M.D.).

Covered. Occupational Therapists. This
provider is covered only when treating
Not Covered: Physical therapy provided as
the upper extremities, which means the
an inpatient in the absence of a separate
arms from the shoulders to the fingers.
medical condition that requires
hospitalization. Optometrists.
Oral Surgeons.
Physical Therapists.
Physician Assistants.
Podiatrists.
Psychologists. Psychologists must
have a doctorate degree in psychology
with two years’ clinical experience and
meet the standards of a national
register.
Speech Pathologists.

Form Number: Wellmark IA Grp/DE_ 1012 23 ZY7 5AQ ZY8 5AR

 Details – Covered and Not Covered

Not Covered: are instances where self-administered

injectable drugs may be covered under
 Athletic Trainers.
this medical benefits plan (e.g., drugs
See Also: given in the muscle or through a vein).
For a list of these drugs, visit our
Choosing a Provider, page 35.
website at www.wellmark.com or check
with your pharmacist or physician.
Prescription Drugs
Covered: Most prescription drugs and Specialty Drugs. Specialty drugs are
medicines that bear the legend, “Caution, high-cost injectable, infused, oral, or
Federal Law prohibits dispensing without a inhaled drugs typically used for treating
prescription,” are generally covered under or managing chronic illnesses. These
the prescription drug plan, not under this drugs often require special handling
medical benefits plan. However, there are (e.g., refrigeration) and administration.
instances when prescription drugs and They are not available through the mail
medicines are covered under this medical order drug program.
benefits plan. Specialty drugs may be covered under
Drugs classified by the FDA as Drug Efficacy this medical benefits plan or under your
Study Implementation (DESI) drugs may prescription drug plan. To determine
also be covered. For a list of these drugs, whether a particular specialty drug is
visit our website at www.wellmark.com or covered under this medical benefits plan
check with your pharmacist or physician. or under your prescription drug plan,
consult the Wellmark Drug List at
Prescription drugs and medicines covered www.wellmark.com, or call the
under this medical benefits plan include: Customer Service number on your ID
Drugs and Biologicals. Certain drugs card.
and biologicals approved by the U.S. Not Covered (some of these may be
Food and Drug Administration are covered under your prescription drug plan).
covered under this medical benefits See the Wellmark Blue Rx Value Plus Drug
plan. This includes such supplies as List at www.wellmark.com or call the
serum, vaccine, antitoxin, or antigen Customer Service number on your ID card
used in the prevention or treatment of and request a copy of the Drug List:
disease.
 Growth hormones.
Intravenous Administration.  Infertility prescription drugs. These
Intravenous administration of nutrients, drugs are not covered under the
antibiotics, and other drugs and fluids Standard Plan.
when provided in the home (home
 Insulin. This is covered under your
infusion therapy).
prescription drug plan.
Nicotine Dependence. Prescription  Prescription drugs and devices used to
drugs and devices used to treat nicotine treat nicotine dependence. You are also
dependence are covered under the not covered for psychotherapy, and x-
prescription drug plan and not under ray and lab services related to nicotine
this medical benefits plan. However, dependence.
related medical evaluations are covered  Prescription drugs that are not FDA-
under this medical benefits plan. approved.
Self-Administered Injectable
See Also:
Drugs. Self-administered injectable
drugs are generally covered under your Medical and Surgical Supplies earlier in
prescription drug plan. However, there this section.
ZY7 5AQ ZY8 5AR 24 Form Number: Wellmark IA Grp/DE_ 1012
 Details – Covered and Not Covered

Prior Authorization, page 45. See Also:

Hearing Services earlier in this section.
Preventive Care
Covered: Vision Services later in this section.

 Physical examinations and related Prosthetic Devices

preventive services such as:
Covered: Devices used as artificial
 Gynecological examinations.
substitutes to replace a missing natural part
 Immunizations. of the body or to improve, aid, or increase
 Mammograms. the performance of a natural function.
 Pap smears.
Also covered are braces, which are rigid or
 Well-child care including age- semi-rigid devices commonly used to
appropriate pediatric preventive support a weak or deformed body part or to
services, as defined by current restrict or eliminate motion in a diseased or
recommendations for Preventive injured part of the body. Braces do not
Pediatric Health Care of the American include elastic stockings, elastic bandages,
Academy of Pediatrics. Pediatric garter belts, arch supports, orthodontic
preventive services shall include, at devices, or other similar items.
minimum, a history and complete
physical examination as well as Not Covered:
developmental assessment, anticipatory  Devices such as eyeglasses and air
guidance, immunizations, and conduction hearing aids or
laboratory services including, but not examinations for their prescription or
limited to, screening for lead exposure fitting.
as well as blood levels.  Elastic stockings or bandages including
trusses, lumbar braces, garter belts, and
Service Maximum:
similar items that can be purchased
 Well-child care until the child reaches without a prescription.
age seven.
See Also:
 One routine physical examination per
benefit year. Home/Durable Medical Equipment earlier
 One routine mammogram per benefit in this section.
year. Medical and Surgical Supplies earlier in
 One routine gynecological examination this section.
per benefit year.
Orthotics earlier in this section.
 One routine Pap smear per benefit year.
Personal Convenience Items in the section
Not Covered: General Conditions of Coverage,
 Routine foot care, including related Exclusions, and Limitations, page 33.
services or supplies.
 Periodic physicals or health Reconstructive Surgery
examinations, screening procedures, or Covered: Reconstructive surgery primarily
immunizations performed solely for intended to restore function lost or
school, sports, employment, insurance, impaired as the result of an illness, injury,
licensing, or travel. or a birth defect (even if there is an
incidental improvement in physical
appearance) including breast reconstructive
surgery following mastectomy. Breast

Form Number: Wellmark IA Grp/DE_ 1012 25 ZY7 5AQ ZY8 5AR

 Details – Covered and Not Covered

reconstructive surgery includes the  Preoperative and postoperative care.

following:
See Also:
 Reconstruction of the breast on which
the mastectomy has been performed. Dental Services earlier in this section.
 Surgery and reconstruction of the other Reconstructive Surgery earlier in this
breast to produce a symmetrical section.
appearance.
 Prostheses. Temporomandibular Joint
 Treatment of physical complications of Disorder (TMD)
the mastectomy, including
lymphedemas. Premium Plan
Covered.
See Also:
Service Maximum:
Cosmetic Services earlier in this section.
 $3,000 per lifetime for treatment.
Self Help Programs Not Covered: Dental extractions, dental
Not Covered: Self-help and self-cure restorations, or orthodontic treatment for
products or drugs. temporomandibular joint disorders.

Sleep Apnea Treatment Standard Plan

Covered: Obstructive sleep apnea  Not Covered. Treatment of
diagnosis and treatments. temporomandibular joint disorder is not
covered under the Standard Plan.
Not Covered: Treatment for snoring
without a diagnosis of obstructive sleep
apnea. Transplants
Covered:
Speech Therapy  Certain bone marrow/stem cell transfers
Covered: Rehabilitative speech therapy from a living donor.
services when related to a specific illness,  Heart.
injury, or impairment and involve the  Heart and lung.
mechanics of phonation, articulation, or
 Kidney.
swallowing. Services must be provided by a
licensed or certified speech pathologist.  Liver.
 Lung.
Not Covered:
 Pancreas.
 Speech therapy services not provided by  Simultaneous pancreas/kidney.
a licensed or certified speech  Small bowel.
pathologist.
 Speech therapy to treat certain Transplants are subject to Case
developmental, learning, or Management.
communication disorders, such as Charges related to the donation of an organ
stuttering and stammering. are usually covered by the recipient’s
medical benefits plan. However, if donor
Surgery charges are excluded by the recipient’s plan,
Covered. This includes the following: and you are a donor, the charges will be
covered by this medical benefits plan.
 Major endoscopic procedures.
 Operative and cutting procedures.

ZY7 5AQ ZY8 5AR 26 Form Number: Wellmark IA Grp/DE_ 1012

 Details – Covered and Not Covered

Not Covered: Not Covered:

 Expenses of transporting a living donor.  Surgery to correct a refractive error (i.e.,
 Expenses related to the purchase of any when the shape of your eye does not
organ. bend light correctly resulting in blurred
 Services or supplies related to images).
mechanical or non-human organs  Eyeglasses or contact lenses, including
associated with transplants. charges related to their fitting.
 Transplant services and supplies not  Prescribing of corrective lenses.
listed in this section including  Eye examinations for the fitting of
complications. eyewear.
 Routine vision examinations.
See Also:
Case Management, page 45. Wigs or Hairpieces
Travel or Lodging Costs later in this Covered: Wigs and hair pieces are covered
section. but only when related to hair loss resulting
from medical treatment, such as
Travel or Lodging Costs chemotherapy treatment.
Covered: Travel and lodging costs when Service Maximum:
related to a transplant received at a Blue
 $400 per lifetime.
Distinction Center for Transplant for the
covered transplant recipient and one
companion, or two companions if the
X-ray and Laboratory
recipient is a covered dependent. Services
Covered: Tests, screenings, imagings, and
Service Maximum:
evaluation procedures as identified in the
 $10,000 per transplant for lodging and American Medical Association's Current
meals. Procedural Terminology (CPT) manual,
Standard Edition, under Radiology
See Also: Guidelines and Pathology and Laboratory
Transplants earlier in this section. Guidelines.
See Also:
Vision Services
Preventive Care earlier in this section.
Covered: Vision examinations but only
when related to an illness or injury.

Prescription Drug Plan

(FDA) and approved for use by the FDA
Guidelines for Drug Coverage after 1962.
To be covered, a prescription drug must  Prescribed by a practitioner prescribing
meet all of the following criteria: within the scope of his or her license.
 Listed on the Wellmark Blue Rx Value  Dispensed by a recognized licensed
Plus Drug List. retail pharmacy employing licensed
registered pharmacists, through the
 Can be legally obtained in the United
specialty pharmacy program, or through
States only with a written prescription.
the mail order drug program.
 Deemed both safe and effective by the
 Medically necessary for your condition.
U.S. Food and Drug Administration
See Medically Necessary, page 31.

Form Number: Wellmark IA Grp/DE_ 1012 27 ZY7 5AQ ZY8 5AR

 Details – Covered and Not Covered

 Not available in an equivalent over-the- They are not available through the mail
counter strength. order drug program.
 Reviewed, evaluated, and recommended Specialty drugs may be covered under your
for addition to the Wellmark Blue Rx prescription drug plan or under your
Value Plus Drug List by Wellmark. medical benefits plan. To determine
whether a particular specialty drug is
Drugs that are Covered covered under your prescription drug plan
or under your medical benefits plan, consult
The Wellmark Blue Rx Value Plus
the Wellmark Blue Rx Value Plus Drug List
Drug List
The Wellmark Blue Rx Value Plus Drug List at www.wellmark.com, check with your
is a reference list that includes generic and pharmacist or physician, or call the
brand-name prescription drugs that have Customer Service number on your ID card.
been approved by the U.S. Food and Drug
Administration (FDA) and are covered Limits on Prescription Drug
under your prescription drug plan. The Coverage
Drug List is updated on a quarterly basis, or We may exclude, discontinue, or limit
when new drugs become available, and as coverage for any drug by removing it from
discontinued drugs are removed from the the Drug List or by moving a drug to a
marketplace. different tier on the Drug List for any of the
following reasons:
To determine if a drug is covered, you must
consult the Wellmark Blue Rx Value Plus  New drugs are developed.
Drug List. You are covered for drugs listed  Generic drugs become available.
on the Wellmark Blue Rx Value Plus Drug  Over-the-counter drugs with similar
List. If a drug is not on the Wellmark Blue properties become available or a drug’s
Rx Value Plus Drug List, it is not covered. active ingredient is available in a similar
If you need help determining if a particular strength in an over-the-counter product
drug is on the Drug List, ask your physician or as a nutritional or dietary supplement
or pharmacist, visit our website, product available over the counter.
www.wellmark.com, or call the Customer  There is a sound medical reason.
Service number on your ID card and request  Scientific evidence does not show that a
a copy of the Drug List. drug works as well and is as safe as other
New drugs will not be added to the Drug drugs used to treat the same or similar
List until they have been evaluated by conditions.
Wellmark. We will periodically update the  A drug receives FDA approval for a new
list to reflect these evaluations and to reflect use.
the changing drug market in general.
Revisions to the list will be distributed to Drugs that are Not Covered
providers who participate with Wellmark, Drugs not covered include but are not
and pharmacies that participate with the limited to:
network used by this prescription drug plan.
 Drugs not listed on the Wellmark Blue
The Drug List is subject to change. Rx Value Plus Drug List.
Specialty Drugs  Drugs in excess of a quantity limitation.
Specialty drugs are high-cost injectable, See Quantity Limitations later in this
infused, oral, or inhaled drugs typically used section.
for treating or managing chronic illnesses.  Drugs that are not FDA approved.
These drugs often require special handling  Experimental or investigational drugs.
(e.g., refrigeration) and administration.

ZY7 5AQ ZY8 5AR 28 Form Number: Wellmark IA Grp/DE_ 1012

 Details – Covered and Not Covered

 Compounded drugs that do not contain a practitioner or hospital and the

an active ingredient in a form that has practitioner or hospital prescribed the
been approved by the FDA and that prescription drug.
require a prescription to obtain.
 Compounded drugs that contain bulk Quantity Limitations
powders or that are commercially Most prescription drugs are limited to a
available as a similar prescription drug. maximum quantity you may receive in a
 Drugs determined to be abused or single prescription.
otherwise misused by you. Federal regulations limit the quantity that
 Drugs that are lost, damaged, stolen, or may be dispensed for certain medications. If
used inappropriately. your prescription is so regulated, it may not
 Contraceptive medical devices, such as be available in the amount prescribed by
intrauterine devices and diaphragms. your physician.
(These are covered under your medical
In addition, coverage for certain drugs is
benefits plan.)
limited to specific quantities per month,
 Convenience packaging. If the cost of benefit year, or lifetime. Amounts in excess
the convenience packaged drug exceeds of quantity limitations are not covered.
what the drug would cost if purchased in
its normal container, the convenience For a list of drugs with quantity limits,
packaged drug is not covered. check with your pharmacist or physician,
 Cosmetic drugs. consult the Wellmark Blue Rx Value Plus
Drug List at www.wellmark.com, or call the
 Growth Hormones.
Customer Service number on your ID card.
 Irrigation solutions and supplies.
 Therapeutic devices or medical Refills
appliances.
To qualify for refill benefits, all of the
 Infertility drugs. following requirements must be met:
See Also:  Sufficient time has elapsed since the last
Prescription Drugs, page 24. prescription was written. Sufficient time
means that at least 75 percent of the
Prescription Purchases medication has been taken according to
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.
 You are injured or become ill while in a  The refill is for use by the person for
foreign country. whom the prescription is written (and
 The prescription drug's active ingredient not someone else).
and dosage form are FDA-approved or  The refill does not exceed the amount
an FDA equivalent and has the same authorized by your practitioner.
name and dosage form as the FDA-  The refill is not limited by state law.
approved drug's active ingredient.
 The prescription drug would require a You are allowed one early refill per
written prescription by a licensed medication per calendar year if you will be
practitioner if prescribed in the U.S. away from home for an extended period of
 You provide acceptable documentation time.
that you received a covered service from

Form Number: Wellmark IA Grp/DE_ 1012 29 ZY7 5AQ ZY8 5AR

 Details – Covered and Not Covered

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.

ZY7 5AQ ZY8 5AR 30 Form Number: Wellmark IA Grp/DE_ 1012

4. General Conditions of Coverage,
Exclusions, and Limitations
The provisions in this section describe considered effective for the patient’s
general conditions of coverage and illness, injury or disease.
important exclusions and limitations that  Not provided primarily for the
apply generally to all types of services or convenience of the patient, physician, or
supplies. other health care provider, and not more
costly than an alternative service or
Conditions of Coverage sequence of services at least as likely to
produce equivalent therapeutic or
Medically Necessary
diagnostic results as to the diagnosis or
A key general condition in order for you to
treatment of the illness, injury or
receive benefits is that the service, supply,
disease.
device, or drug must be medically necessary.
Even a service, supply, device, or drug listed An alternative service, supply, device, or
as otherwise covered in Details - Covered drug may meet the criteria of medical
and Not Covered may be excluded if it is not necessity for a specific condition. If
medically necessary in the circumstances. alternatives are substantially equal in
Wellmark determines whether a service, clinical effectiveness and use similar
supply, device, or drug is medically therapeutic agents or regimens, we reserve
necessary, and that decision is final and the right to approve the least costly
conclusive. Even though a provider may alternative.
recommend a service or supply, it may not
be medically necessary. If you receive services that are not medically
necessary, you are responsible for the cost
A medically necessary health care service is if:
one that a provider, exercising prudent
clinical judgment, provides to a patient for  You receive the services from a
the purpose of preventing, evaluating, nonparticipating provider; or
diagnosing or treating an illness, injury,  You receive the services from a PPO or
disease or its symptoms, and is: participating provider in Iowa and South
Dakota and:
 Provided in accordance with generally
 The provider informs you in writing
accepted standards of medical practice.
before rendering the services that
Generally accepted standards of medical
Wellmark determined the services to
practice are based on:
be not medically necessary; and
 Credible scientific evidence
 The provider gives you a written
published in peer-reviewed medical
estimate of the cost for such services
literature generally recognized by
and you agree in writing, before
the relevant medical community;
receiving the services, to assume the
 Physician Specialty Society
payment responsibility.
recommendations and the views of
physicians practicing in the relevant If you do not receive such a written
clinical area; and notice, and do not agree in writing to
 Any other relevant factors. assume the payment responsibility for
 Clinically appropriate in terms of type, services that Wellmark determined are
frequency, extent, site and duration, and not medically necessary, the PPO or

Form Number: Wellmark IA Grp/GC_ 1012 31 ZY7 5AQ ZY8 5AR

 General Conditions of Coverage, Exclusions, and Limitations

participating provider is responsible for  The health improvement is attainable

these amounts. outside the investigational setting.
 You are also responsible for the cost if These criteria are considered by the Blue
you receive services from a provider Cross and Blue Shield Association's Medical
outside of Iowa and South Dakota that Advisory Panel for consideration by all Blue
Wellmark determines to be not Cross and Blue Shield member
medically necessary. This is true even if organizations. While we may rely on these
the provider does not give you any criteria, the final decision remains at the
written notice before the services are discretion of our Medical Director, whose
rendered. decision may include reference to, but is not
controlled by, policies or decisions of other
Member Eligibility
Blue Cross and Blue Shield member
Another general condition of coverage is
organizations. You may access our medical
that the person who receives services must
policies, with supporting information and
meet requirements for member eligibility.
selected medical references for a specific
See Coverage Eligibility and Effective Date,
service, supply, device, or drug through our
page 53.
website, www.wellmark.com.
General Exclusions If you receive services that are
Even if a service, supply, device, or drug is investigational or experimental, you are
listed as otherwise covered in Details - responsible for the cost if:
Covered and Not Covered, it is not eligible  You receive the services from a
for benefits if any of the following general nonparticipating provider; or
exclusions apply.
 You receive the services from a PPO or
Investigational or Experimental participating provider in Iowa and South
You are not covered for a service, supply, Dakota and:
device, or drug that is investigational or  The provider informs you in writing
experimental. A treatment is considered before rendering the services that
investigational or experimental when it has Wellmark determined the services to
progressed to limited human application be investigational or experimental;
but has not achieved recognition as being and
proven effective in clinical medicine.  The provider gives you a written

To determine investigational or estimate of the cost for such services

experimental status, we may refer to the and you agree in writing, before
technical criteria established by the Blue receiving the services, to assume the
Cross and Blue Shield Association, payment responsibility.
including whether a service, supply, device, If you do not receive such a written
or drug meets these criteria: notice, and do not agree in writing to
 It has final approval from the assume the payment responsibility for
appropriate governmental regulatory services that Wellmark determined to be
bodies. investigational or experimental, the PPO
 The scientific evidence must permit or participating provider is responsible
conclusions concerning its effect on for these amounts.
health outcomes.  You are also responsible for the cost if
 It improves the net health outcome. you receive services from a provider
 It is as beneficial as any established outside of Iowa and South Dakota that
alternatives. Wellmark determines to be
investigational or experimental. This is

ZY7 5AQ ZY8 5AR 32 Form Number: Wellmark IA Grp/GC_ 1012

 General Conditions of Coverage, Exclusions, and Limitations

true even if the provider does not give unpaid by your other carrier, including
you any written notice before the deductible, coinsurance, or copayments.
services are rendered.  You require services or supplies for an
illness or injury sustained while on
Complications of a Noncovered
active military status.
Service
You are not covered for a complication Workers’ Compensation
resulting from a noncovered service, supply, You are not covered for services or supplies
device, or drug. that are compensated under workers’
compensation laws, including services or
Nonmedical Services
supplies applied toward satisfaction of any
You are not covered for telephone
deductible under your employer’s workers’
consultations, charges for missed
compensation coverage. You are also not
appointments, charges for completion of
covered for any services or supplies that
any form, or charges for information.
could have been compensated under
Personal Convenience Items workers’ compensation laws if you had
You are not covered for items used for your complied with the legal requirements
personal convenience, such as: relating to notice of injury, timely filing of
claims, and medical treatment
 Items not primarily and customarily
authorization.
manufactured to serve a medical
purpose or which can be used in the Benefit Limitations
absence of illness or injury (including,
Benefit limitations refer to amounts for
but not limited to, air conditioners,
which you are responsible under this group
dehumidifiers, ramps, home
health plan. These amounts are not credited
remodeling, hot tubs, swimming pools);
toward your out-of-pocket maximum. In
or
addition to the exclusions and conditions
 Items that do not serve a medical described earlier, the following are
purpose or are not needed to serve a examples of benefit limitations under this
medical purpose. group health plan:
Provider Is Family Member  A service or supply that is not covered
You are not covered for a service or supply under this group health plan is your
received from a provider who is in your responsibility.
immediate family (which includes yourself,  If a covered service or supply reaches a
parent, child, or spouse or domestic service or prescription maximum, it is
partner). no longer eligible for benefits. (A
Covered by Other Programs or Laws maximum may renew at the next benefit
You are not covered for a service, supply, year.) See Details – Covered and Not
device, or drug if: Covered, page 15.
 If you receive benefits that reach a
 You are entitled to claim benefits from a lifetime benefits maximum applicable to
governmental program (other than any specific service, then you are no
Medicaid). longer eligible for benefits for that
 Someone else has the legal obligation to service under this group health plan. See
pay for services and without this group Lifetime Benefits Maximum, page 9, and
health plan, you would not be charged. At a Glance–Covered and Not Covered,
 Prescription drug claims are submitted page 11.
to another insurance carrier. We will not  If you do not obtain precertification for
reimburse you for amounts that are certain medical services, benefits can be

Form Number: Wellmark IA Grp/GC_ 1012 33 ZY7 5AQ ZY8 5AR

 General Conditions of Coverage, Exclusions, and Limitations

reduced or denied. You are responsible See Choosing a Provider, page 35, and
for these benefit reductions or denials Factors Affecting What You Pay, page
only if you are responsible (not your 47. Examples of charges that depend on
provider) for notification. A PPO the type of provider include but are not
provider in Iowa or South Dakota may limited to:
handle notification requirements for  Any difference between the
you. If you see a PPO provider outside provider’s amount charged and our
Iowa or South Dakota, you are amount paid is your responsibility if
responsible for notification you receive services from a
requirements. See Notification nonparticipating provider.
Requirements and Care Coordination,
page 41.
 If you do not obtain prior approval for
certain medical services, benefits will be
denied on the basis that you did not
obtain 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 this medical benefits
plan. Upon review, if we determine the
service was medically necessary and a
benefit under this medical benefits plan,
benefits for that service will be provided
according to the terms of this medical
benefits plan.

You are responsible for these benefit

denials only if you are responsible (not
your provider) for notification. A PPO
provider in Iowa or South Dakota will
handle notification requirements for
you. If you see a PPO provider outside
Iowa or South Dakota, you are
responsible for notification
requirements. See Notification
Requirements and Care Coordination,
page 41.
 If you do not obtain prior authorization
for certain prescription drugs, benefits
can be reduced or denied. See
Notification Requirements and Care
Coordination, page 41.
 The type of provider you choose can
affect your benefits and what you pay.

ZY7 5AQ ZY8 5AR 34 Form Number: Wellmark IA Grp/GC_ 1012

5. Choosing a Provider
Medical Benefits Plan
For types of providers that may be covered
PPO Providers under this medical benefits plan, see
This medical benefits plan relies on a Hospitals and Facilities, page 20 and
preferred provider organization (PPO) Physicians and Practitioners, page 23.
network, which consists of providers that Please note: Even though a facility may be
participate directly with Wellmark and PPO or participating, particular providers
providers that participate with other Blue within the facility may not be PPO or
Cross and/or Blue Shield preferred provider participating providers. Examples include
organizations (PPOs). These PPO providers nonparticipating physicians on the staff of a
offer services to members of contracting PPO or participating hospital, home medical
medical benefits plans at a reduced cost, equipment suppliers, and other
which usually results in the least expense for independent providers. Therefore, when you
you. are referred by a PPO or participating
provider to another provider, or when you
Non-PPO Providers are admitted into a facility, always ask if the
Non-PPO providers are defined as providers contract with a Blue Cross and/or
participating and nonparticipating Blue Shield Plan.
providers.
Always carry your ID card and present it
Participating Providers when you receive services. Information on
If you are unable to utilize a PPO provider, it, especially the ID number, is required to
it is usually to your advantage to visit what process your claims correctly.
we call a participating provider.
Pharmacies do not participate with this
Participating providers participate with a
medical benefits plan.
Blue Cross and/or Blue Shield Plan, but not
with a PPO.
Specialists
Nonparticipating Providers If you require services from a specialist, you
Other providers are considered should utilize a PPO provider whenever
nonparticipating, and you will usually pay possible. However, if you require services
the most for services you receive from them. that are not available from a PPO specialist
within 30 miles of your home address, you
See What You Pay, page 3 and Factors
may utilize a non-PPO specialist who has
Affecting What You Pay, page 47.
expertise in diagnosing and treating your
Provider Status condition. Please note: Wellmark must
approve non-PPO specialist services before
To determine if a provider participates with
you receive the services. Even after you
this medical benefits plan, ask your
receive approval, you are still responsible
provider, visit our website at
for complying with notification
www.wellmark.com, or www.bcbs.com,
requirements. See Notification
refer to your provider directory (a separate
Requirements and Care Coordination, page
document that's available, without charge),
41.
or call 800-810-BLUE.

Form Number: Wellmark IA Grp/CP_ 1012 35 ZY7 5AQ ZY8 5AR

 Choosing a Provider

Non-PPO

Nonparticipating
Provider Comparison Chart

Participating
PPO
Accepts Blue Cross and/or Blue Shield payment arrangements. Yes Yes No
Minimizes your payment obligations. See What You Pay, page 3. Yes No No
Claims are filed for you. Yes Yes No
Blue Cross and/or Blue Shield pays these providers directly. Yes Yes No
Notification requirements are handled for you. Yes* No No
*If you visit a PPO provider outside Iowa and South Dakota, you are responsible for notification requirements. See Services
Outside Iowa and South Dakota later in this section.
considered a nonparticipating provider and
Services Outside Iowa and you will be responsible for any applicable
South Dakota nonparticipating provider payment
Whenever possible, before receiving services obligations and you may also be responsible
outside Iowa and South Dakota, you should for any difference between the amount
ask the provider if he or she participates charged and our amount paid for the
with a Blue Cross and/or Blue Shield Plan in covered service.
that state. To locate PPO providers in any If you purchase or rent home/durable
state, call 800-810-BLUE, or visit medical equipment and have that
www.bcbs.com. equipment shipped to a service area of a
Laboratory services. You may have Blue Plan that does not have a contractual
laboratory specimens or samples collected relationship with the home/durable medical
by a PPO provider and those laboratory equipment provider, that provider will be
specimens may be sent to another considered nonparticipating and you will be
laboratory services provider for processing responsible for any applicable
or testing. If that laboratory services nonparticipating provider payment
provider does not have a contractual obligations and you may also be responsible
relationship with the Blue Plan where the for any difference between the amount
specimen was drawn, that provider will be charged and our amount paid for the
considered a nonparticipating provider and covered service. This includes situations
you will be responsible for any applicable where you purchase or rent home/durable
nonparticipating provider payment medical equipment and have the equipment
obligations and you may also be responsible shipped to you in Iowa and South Dakota,
for any difference between the amount when Wellmark does not have a contractual
charged and our amount paid for the relationship with the home/durable medical
covered service. equipment provider.

Home/durable medical equipment. If Prosthetic devices. If you purchase

you purchase or rent home/durable medical prosthetic devices from a provider that does
equipment from a provider that does not not have a contractual relationship with the
have a contractual relationship with the Blue Plan where you purchased the
Blue Plan where you purchased or rented prosthetic devices, that provider will be
the equipment, that provider will be considered a nonparticipating provider and
you will be responsible for any applicable
ZY7 5AQ ZY8 5AR 36 Form Number: Wellmark IA Grp/CP_ 1012
 Choosing a Provider

nonparticipating provider payment Participating providers have a contractual

obligations and you may also be responsible agreement with the Blue Cross or Blue
for any difference between the amount Shield Plan in their home state (“Host
charged and our amount paid for the Blue”). The Host Blue is responsible for
covered service. contracting with and generally handling all
interactions with its participating providers.
If you purchase prosthetic devices and have
that equipment shipped to a service area of The BlueCard Program is one of the
a Blue Plan that does not have a contractual advantages of your coverage with Wellmark
relationship with the provider, that provider Blue Cross and Blue Shield of Iowa. It
will be considered nonparticipating and you provides conveniences and benefits outside
will be responsible for any applicable Iowa and South Dakota similar to those you
nonparticipating provider payment would have within Iowa and South Dakota
obligations and you may also be responsible when you obtain covered medical services
for any difference between the amount from a BlueCard PPO provider. Always
charged and our amount paid for the carry your ID card (or BlueCard) and
covered service. This includes situations present it to your provider when you receive
where you purchase prosthetic devices and care. Information on it, especially the ID
have them shipped to you in Iowa and South number, is required to process your claims
Dakota, when Wellmark does not have a correctly.
contractual relationship with the provider.
BlueCard PPO providers may not be
Talk to your provider. Whenever available in some states. In this case, when
possible, before receiving laboratory you receive covered services from a non-
services, home/durable medical equipment, BlueCard PPO provider, you will receive the
or prosthetic devices, ask your provider to same advantages as when you receive
utilize a provider that has a contractual covered services from a BlueCard PPO
arrangement with the Blue Plan where you provider.
received services, purchased or rented
BlueCard PPO providers contract with the
equipment, or shipped equipment, or ask
Blue Cross and/or Blue Shield preferred
your provider to utilize a provider that has a
provider organization (PPO) in their home
contractual arrangement with Wellmark.
state.
To determine if a provider has a contractual
When you receive covered services from
arrangement with a particular Blue Plan or
BlueCard providers outside Iowa and South
with Wellmark, call the Customer Service
Dakota, all of the following statements are
number on your ID card or visit our website,
true:
www.wellmark.com.
 Claims are filed for you.
See Nonparticipating Providers, page 48.
 These providers agree to accept payment
BlueCard Program. We have arrangements or negotiated prices of the
relationships with other Blue Cross and/or Blue Cross and/or Blue Shield Plan with
Blue Shield Plans. These relationships are which the provider contracts. These
generally referred to as Inter-Plan payment arrangements may result in
Programs. Whenever you obtain services savings.
outside Iowa or South Dakota, the claims for  The health plan payment is sent directly
these services may be processed through to the providers.
one of these Inter-Plan Programs, which
include the BlueCard Program. These When you receive covered services from
programs ensure that members of any Blue BlueCard providers outside Iowa and South
Plan have access to the advantages of PPO Dakota, you are responsible for notification
providers throughout the United States. requirements. See Notification

Form Number: Wellmark IA Grp/CP_ 1012 37 ZY7 5AQ ZY8 5AR

 Choosing a Provider

Requirements and Care Coordination, page payment level assumes the provider
41. category is nonparticipating except for
services received from providers that
Care in a Foreign Country participate with BlueCard Worldwide.
For covered services you receive in a
country other than the United States,

Prescription Drug Plan

Choosing a Pharmacy Advantages of Visiting Participating

Pharmacies
Pharmacies that participate with the When you fill your prescription at
network used by this prescription drug plan participating pharmacies:
are called participating pharmacies.
Pharmacies that do not participate with the  You will usually pay less. If you use a
network are called nonparticipating nonparticipating pharmacy, you must
pharmacies. pay the amount charged at the time of
purchase, and the amount we reimburse
To determine if a pharmacy is participating, you may be less than what you paid. You
ask the pharmacist, consult the directory of are responsible for this difference.
participating pharmacies (a separate
 The participating pharmacist can check
document available without charge), visit
whether your prescription is subject to
our website at www.wellmark.com, or call
prior authorization or quantity limits.
us.
 The participating pharmacist can access
This prescription drug plan allows you to your benefit information, verify your
purchase most covered prescription drugs eligibility, check whether the
from almost any pharmacy you choose. prescription is a benefit under this
However, you will usually pay more for prescription drug plan, list the amount
prescription drugs when you purchase them you are expected to pay, and suggest
from nonparticipating pharmacies. generic alternatives.
Remember, you are responsible for the
entire cost if you purchase a drug that is not Always Present Your ID Card
on the Wellmark Drug List. We recommend If you do not have your ID card with you
you: when you fill a prescription at a
participating pharmacy, the pharmacist may
 Fill your prescriptions at a participating
not be able to access your benefit
retail pharmacy, through the specialty
information. In this case:
pharmacy program, or through the mail
order drug program. See Mail Order  You must pay the full amount charged at
Drug Program and Specialty Pharmacy the time you receive your prescription,
Program later in this section. and the amount we reimburse you may
 Advise your physician that you are be less than what you paid. You are
covered under this prescription drug responsible for this difference.
plan.  You must file your claim to be
 Always present your ID card when filling reimbursed. See Claims, page 73.
prescriptions. Your ID card enables
participating pharmacists to access your Specialty Pharmacy Program
benefits information. Specialty drugs are often unavailable from
ordinary retail pharmacies. Specialty
pharmacies deliver specialty drugs directly
to your home or to your physician's office.
We recommend that you purchase specialty
ZY7 5AQ ZY8 5AR 38 Form Number: Wellmark IA Grp/CP_ 1012
 Choosing a Provider

drugs through a participating pharmacy or www.wellmark.com, or call the Customer

through the specialty pharmacy program. Service number on your ID card.
You must register as a specialty pharmacy
Mail order pharmacy providers outside our
program user in order to fill your
mail order program are considered
prescriptions through the specialty
nonparticipating pharmacies. If you
pharmacy program. For information on how
purchase covered drugs from
to register, call the Customer Service
nonparticipating mail order pharmacies,
number on your ID card or visit our website
you will usually pay more.
at www.wellmark.com.
When you purchase covered drugs from
The specialty pharmacy program
nonparticipating pharmacies you are
administers the distribution of specialty
responsible for the amount charged for the
drugs to the home and to physicians' offices.
drug at the time you fill your prescription,
When you fill your prescription through the and then you must file a claim to be
specialty pharmacy program, you will reimbursed. Once you submit a claim, you
usually pay less than if you use a pharmacy will receive credit toward your deductible or
outside the specialty pharmacy program. be reimbursed up to the maximum
allowable fee of the drug, less your payment
For specialty drug purchases, pharmacies
obligation. The maximum allowable fee may
outside the specialty pharmacy program are
be less than the amount you paid. In other
considered nonparticipating pharmacies.
words, you are responsible for any
When you purchase covered drugs from
difference in cost between what the
nonparticipating pharmacies, you will
pharmacy charges you for the drug and our
usually pay more.
reimbursement amount.
When you purchase covered drugs from
See Participating vs. Nonparticipating
nonparticipating pharmacies you are
Pharmacies, page 50.
responsible for the amount charged for the
drug at the time you fill your prescription,
and then you must file a claim to be
reimbursed. Once you submit a claim, you
will receive credit toward your deductible or
be reimbursed up to the maximum
allowable fee of the drug, less your payment
obligation. The maximum allowable fee may
be less than the amount you paid. In other
words, you are responsible for any
difference in cost between what the
pharmacy charges you for the drug and our
reimbursement amount.

Mail Order Drug Program

When you fill your prescription through the
mail order drug program, you will usually
pay less than if you use a nonparticipating
mail order pharmacy.
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,

Form Number: Wellmark IA Grp/CP_ 1012 39 ZY7 5AQ ZY8 5AR

6. Notification Requirements and Care
Coordination
Medical Benefits Plan
Many 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
www.wellmark.com or call the Customer Service number on your ID card.

BlueCard Providers and Notification Requirements

Only BlueCard providers in Iowa and South Dakota handle notification requirements for you. If
you receive services from a BlueCard provider outside Iowa or South Dakota, you or someone
acting on your behalf are 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 plan 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 or
reduction of benefits resulting from these notification requirements and care coordination
programs. See Appeals, page 81. Also see Authorized Representative, page 85.

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
www.wellmark.com or call the Customer Service number on your ID card.
Person PPO providers in the states of Iowa and South Dakota obtain precertification for
Responsible you. However, you or someone acting on your behalf are responsible for
precertification if:
 You are admitted to a facility outside Iowa or South Dakota;
 You receive services subject to precertification from a provider outside Iowa
or South Dakota;
 You receive services subject to precertification from a non-PPO provider.

Form Number: Wellmark IA Grp/NR_ 1012 41 ZY7 5AQ ZY8 5AR

 Notification Requirements and Care Coordination

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. Requests without
adequate supporting information will be denied if documentation is not
provided within 48 hours of the initial request.
Importance If you choose to receive services subject to precertification and we determine
that the procedure was not medically necessary, you will be responsible for the
charges.
If we determine the procedure is medically necessary and otherwise covered,
without precertification, benefits will be reduced by 50% of the maximum
allowable fee, after which we subtract your applicable payment obligations. The
maximum reduction will not exceed $500 per admission. See Maximum
Allowable Fee, page 48. You are subject to this benefit reduction only if you
(instead of your provider) are responsible for notification.
Reduced or 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
www.wellmark.com or call the Customer Service number on your ID card.
Person PPO providers in the states of Iowa and South Dakota perform notification for
Responsible you. However, you or someone acting on your behalf are responsible for
notification if:
 You are admitted to a facility outside Iowa or South Dakota;
 You receive services subject to notification from a provider outside Iowa or
South Dakota;
 You receive services subject to notification from a participating or
nonparticipating provider.

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.

ZY7 5AQ ZY8 5AR 42 Form Number: Wellmark IA Grp/NR_ 1012

 Notification Requirements and Care Coordination

Prior Approval
Purpose Prior approval helps determine whether a proposed treatment plan is medically
necessary and a benefit under this medical benefits plan. Prior approval is
required.
Applies to For a complete list of the services subject to prior approval, visit
www.wellmark.com or call the Customer Service number on your ID card.
Person PPO providers in the states of Iowa and South Dakota request prior approval for
Responsible you. You are responsible for prior approval if:
 You are admitted to a facility outside Iowa or South Dakota;
 You received services subject to prior approval from a provider outside Iowa
or South Dakota;
 You receive services subject to prior approval from a participating or
nonparticipating provider.

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. Requests without
adequate supporting information will be denied if documentation is not
provided within 48 hours of the initial request.

Form Number: Wellmark IA Grp/NR_ 1012 43 ZY7 5AQ ZY8 5AR

 Notification Requirements and Care Coordination

Importance If your request is approved, the service is covered provided other contractual
requirements, such as member eligibility and service 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 this medical benefits plan. Upon review, if we determine the
service was medically necessary and a benefit under this medical benefits plan,
the benefit for that service will be provided according to the terms of this
medical benefits plan.
Approved services are eligible for benefits for a limited time. Approval is based
on the medical benefits plan 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 a new medical benefits plan), 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
www.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.
Concurrent review requests must include supporting clinical information to
determine medical necessity as a condition of your coverage. Requests that do
not include supporting information may be denied for lack of information, if
documentation is not provided within 48 hours of initial request.
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.

ZY7 5AQ ZY8 5AR 44 Form Number: Wellmark IA Grp/NR_ 1012

 Notification Requirements and Care Coordination

Case Management
Purpose Case management is a process of considering alternative treatments for
members with severe illnesses or injuries that require costly, long-term care.
Depending on the individual circumstances, a hospital may not be the most
appropriate setting for treatment.
Applies to Examples where case management might be appropriate include but are not
limited to:
Brain or Spinal Cord Injuries
Cystic Fibrosis
Degenerative Muscle Disorders
Hemophilia
Home Health Services
Pregnancy (high risk)
Transplants
Person You, your physician, and the health care facility can work with Wellmark’s case
Responsible managers to identify and arrange alternative treatment plans to meet special
needs. Wellmark may initiate a request for case management.
Process Wellmark’s case managers try to identify alternative settings or treatment plans,
provided costs do not exceed those of an inpatient facility. A benefit program is
tailored to the circumstances of the case.
Even if a service is not covered or is subject to a specific limitation, Wellmark
may waive exclusions or limitations with the agreement of its medical director.
If your current level or setting of care is no longer medically necessary, you, your
attending physician, and the facility or agency will be notified at least 24 hours
before benefits end.
Importance Case management provides an opportunity to receive alternative benefits to
meet special needs. Wellmark may recommend a different treatment plan that
preserves coverage.

Prescription Drug Plan

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 Prior authorization is required for a number of particular drugs. Visit

www.wellmark.com or check with your pharmacist or practitioner to determine
whether prior authorization applies to a drug that has been prescribed for you.

Form Number: Wellmark IA Grp/NR_ 1012 45 ZY7 5AQ ZY8 5AR

 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. Nonparticipating pharmacists will fill a
prescription without prior authorization but you will be responsible for paying
the charge.
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 request prior
authorization, you are responsible for paying the entire amount charged.

Exception Process for Noncovered Drugs

Purpose The exception process may allow a drug that is not normally covered to be
covered if it meets Wellmark’s medical exception criteria.
Applies to Drugs not listed on the Wellmark Drug List.
Process There are two exception processes depending upon whether a noncovered drug
has already been purchased or not.
 If you have not already purchased the noncovered drug:
 You may call the Customer Service number on your ID card; or
 You may access the Member Initiated Exception Request Form for
Noncovered Pharmaceuticals on our website at www.wellmark.com; or
 You or your practitioner may follow the prior authorization process
described earlier in this section.
 If you have already purchased the noncovered drug, you will need to see
your practitioner for details on the medical exception process.

Importance If you purchase a drug that is not covered, you are responsible for paying the
entire amount charged.

ZY7 5AQ ZY8 5AR 46 Form Number: Wellmark IA Grp/NR_ 1012

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 Plan

Occasionally, the negotiated price may be an
Benefit Year average price based on a discount that
A benefit year is the same as a calendar year results in expected average savings for
and starts over each January 1. It continues similar types of healthcare providers after
even if you change benefits under the taking into account the same types of
medical benefits plan sponsored by your transactions as with an estimated price.
plan sponsor and administered by Wellmark Estimated pricing and average pricing,
Blue Cross and Blue Shield of Iowa. going forward, also take into account
adjustments to correct for over- or under-
The benefit year is important for
estimation of modifications of past pricing
calculating:
for the types of transaction modifications
 Deductible. noted previously. However, such
 Coinsurance. adjustments will not affect the price we use
 Out-of-pocket maximum. for your claim because they will not be
 Service maximum. applied retroactively to claims already paid.
Laws in a small number of states may
How Coinsurance is require a surcharge be added to your
Calculated calculation. If any state laws mandate other
The coinsurance for covered services is liability calculation methods, including a
calculated on the lower of: surcharge, Wellmark will calculate your
payment obligation for any covered services
 The amount charged for the covered according to applicable law. For more
service, or information, see BlueCard Program, page
 The negotiated price after the following 37.
amounts (if applicable) are subtracted
from it: PPO Providers
 Deductible. Blue Cross and Blue Shield Plans have
 Certain copayments. contracting relationships with PPO
 Amounts representing any general providers. When you receive services from
exclusions and conditions. See PPO providers:
General Conditions of Coverage,  These providers agree to accept
Exclusions, and Limitations, page Wellmark’s payment arrangements, or
31. payment arrangements or negotiated
Often, the negotiated price will be a simple prices of the Blue Cross and Blue Shield
discount that reflects an actual price paid to Plan with which the provider contracts.
your provider. Sometimes, the negotiated These payment arrangements may result
price is an estimated price that takes into in savings.
account special arrangements with your  The health plan payment is sent directly
healthcare provider or provider group that to the provider.
may include types of settlements, incentive
payments, and/or other credits or charges.

Form Number: Wellmark IA Grp/YP_ 1012 47 ZY7 5AQ ZY8 5AR

 Factors Affecting What You Pay

Non-PPO Providers  The health plan does not make claim

payments directly to these providers.
Participating Providers You are responsible for ensuring that
Participating providers participate with a your provider is paid in full.
Blue Cross and/or Blue Shield Plan, but not  The health plan payment for
with a PPO. When you receive services from nonparticipating hospitals, M.D.s, and
participating providers: D.O.s in Iowa is made payable to the
 These providers agree to accept provider, but the check is sent to you.
Wellmark’s payment arrangements or You are responsible for forwarding the
payment arrangements or negotiated check to the provider (plus any billed
prices of the Blue Cross and Blue Shield balance you may owe).
Plan with which the provider contracts.
These payment arrangements may result Amount Charged and
in savings. Maximum Allowable Fee
 The health plan payment is sent directly
Amount Charged
to the provider.
The amount charged is the amount a
provider charges for a service or supply,
Nonparticipating Providers
regardless of whether the services or
Wellmark and Blue Cross and/or Blue supplies are covered under this medical
Shield Plans do not have contracting benefits plan.
relationships with nonparticipating
providers, and they may not accept our Maximum Allowable Fee
payment arrangements. Pharmacies are The maximum allowable fee is the amount,
considered nonparticipating providers. established by Wellmark, using various
Therefore, when you receive services from methodologies, for covered services and
nonparticipating providers: supplies. Wellmark’s amount paid may be
 You are responsible for any difference based on the lesser of the amount charged
between the amount charged and our for a covered service or supply or the
payment for a covered service. In the maximum allowable fee.
case of services received outside Iowa or For professional services, Wellmark utilizes
South Dakota, our maximum payment the Resource Based Relative Value System
for services by a nonparticipating methodology. This approach assigns a
provider will generally be based on Relative Value Unit to a majority of
either the Host Blue’s nonparticipating procedures. The Relative Value Unit is then
provider local payment or the pricing multiplied by a Wellmark established
arrangements required by applicable conversion factor or dollar value to create a
state law. In certain situations, we may Maximum Allowable Fee. This fee schedule
use other payment bases, such as the is implemented statewide for all of
amount charged for a covered service, Wellmark’s contracted professional
the payment we would make if the providers and is updated annually in July.
services had been obtained within Iowa
or South Dakota, or a special negotiated Payment Arrangements
payment, as permitted under Inter-Plan
Programs policies, to determine the Payment Arrangement Savings
amount we will pay for services you Payment arrangements and other important
receive from nonparticipating providers. amounts will appear on your Explanation of
See Services Outside Iowa and South Benefits statement as follows:
Dakota, page 36.  Network Savings, which reflects the
amount you save on a claim by receiving

ZY7 5AQ ZY8 5AR 48 Form Number: Wellmark IA Grp/YP_ 1012

 Factors Affecting What You Pay

services from a participating or PPO amount by subtracting the following

provider. For the majority of services, amounts (if applicable) from the amount
the savings reflects the actual amount charged:
you save on a claim. However,  Deductible.
depending on many factors, the amount  Coinsurance.
we pay a provider could be different
 Copayment.
from the covered charge. Regardless of
 Amounts representing any general
the amount we pay a participating or
exclusions and conditions.
PPO provider, your payment
responsibility will always be based on  Network savings.

the lesser of the covered charge or the

Payment Method for Services
maximum allowable fee.
Provider payment arrangements are
 Amount Not Covered, which reflects the calculated using industry methods,
portion of provider charges not covered including but not limited to fee schedules,
under this health plan and for which you per diems, percentage of charge, or episodes
are responsible. This amount may of care. Some provider payment
include services or supplies not covered; arrangements may include an amount
amounts in excess of a service payable to the provider based on the
maximum, benefit year maximum, or provider’s performance. Performance-based
lifetime benefits maximum; reductions amounts that are not distributed are not
or denials for failure to follow a required allocated to your specific group or to your
precertification; and the difference specific claims and are not considered when
between the amount charged and the determining any amounts you may owe. We
maximum allowable fee for services reserve the right to change the methodology
from a nonparticipating provider. For we use to calculate payment arrangements
general exclusions and examples of based on industry practice or business need.
benefit limitations, see General PPO and participating providers agree to
Conditions of Coverage, Exclusions, and accept our payment arrangements as full
Limitations, page 31. settlement for providing covered services,
 Amount Paid by Health Plan, which except to the extent of any amounts you may
reflects our payment responsibility to a owe.
provider or to you. We determine this

Prescription Drug Plan

Benefit Year Tiers

The Wellmark Drug List identifies which
A benefit year is the same as a calendar
tier a drug is on:
year. It begins on the day your coverage
goes into effect and starts over each January Tier 1. Most generic drugs and some brand-
1. name drugs that have no generic equivalent.
Tier 1 drugs have the lowest payment
The benefit year is important for
obligation.
calculating:
Tier 2. Drugs appear on this tier because
 Deductible.
they either have no generic equivalent or are
considered less cost-effective than Tier 1
drugs. Tier 2 drugs have an intermediate
payment obligation.
Tier 3. Drugs appear on this tier because
they are less cost-effective than Tier 1 or
Form Number: Wellmark IA Grp/YP_ 1012 49 ZY7 5AQ ZY8 5AR
 Factors Affecting What You Pay

Tier 2 drugs. Tier 3 drugs have the highest In addition, coverage for certain drugs is
payment obligation. limited to specific quantities per month,
benefit year, or lifetime. Amounts in excess
Generic and Brand Name of quantity limitations are not covered.
Drugs For a list of drugs with quantity limits,
Generic Drug check with your pharmacist or physician or
Generic drug refers to an FDA-approved consult the Wellmark Drug List at
“A”-rated generic drug. This is a drug with www.wellmark.com, or call the Customer
active therapeutic ingredients chemically Service number on your ID card.
identical to its brand name drug
counterpart.
Amount Charged and
Maximum Allowable Fee
Brand Name Drug
Brand name drug is a prescription drug Amount Charged
patented by the original manufacturer. The retail price charged by a pharmacy for a
Usually, after the patent expires, other covered prescription drug.
manufacturers may make FDA-approved
Maximum Allowable Fee
generic copies.
The amount, established by Wellmark using
Sometimes, a patent holder of a brand name various methodologies and data (such as the
drug grants a license to another average wholesale price), payable for
manufacturer to produce the drug under a covered drugs.
generic name, though it remains subject to
The maximum allowable fee may be less
patent protection and has a nearly identical
than the amount charged for the drug.
price. In these cases, Wellmark’s pharmacy
benefits manager may treat the licensed Participating vs.
product as a brand name drug, rather than
generic, and will calculate your payment
Nonparticipating Pharmacies
obligation accordingly. If you purchase a covered prescription drug
at a nonparticipating pharmacy, you are
What You Pay responsible for the amount charged for the
In most cases, when you purchase a brand drug at the time you fill your prescription,
name drug that has an FDA-approved “A”- and then you must file a claim.
rated generic equivalent, the plan will pay
Once you submit a claim, you will receive
only what it would have paid for the
credit toward your deductible or be
equivalent generic drug. You will be
reimbursed up to the maximum allowable
responsible for your payment obligation for
fee of the drug, less your copayment. The
the brand name drug and any remaining
maximum allowable fee may be less than
cost difference up to the maximum allowed
the amount you paid. In other words, you
fee for the brand name drug.
are responsible for any difference in cost
between what the pharmacy charges you for
Quantity Limitations
the drug and our reimbursement amount.
Most prescription drugs are limited to a
maximum quantity you may receive in a Your payment obligation for the purchase of
single prescription. a covered prescription drug at a
participating pharmacy is the lesser of your
Federal regulations limit the quantity that copayment, the maximum allowable fee, or
may be dispensed for certain medications. If the amount charged for the drug.
your prescription is so regulated, it may not
be available in the amount prescribed by
your physician.

8FL 3VJ 8FM 3VK 50 Form Number: Wellmark IA Grp/YP_ 1010

 Factors Affecting What You Pay

Special Programs Visit our website at www.wellmark.com or

We evaluate and monitor changes in the call us to determine whether your
pharmaceutical industry in order to prescription qualifies.
determine clinically effective and cost-
effective coverage options. These
Savings
evaluations may prompt us to offer Payment Arrangements
programs that encourage the use of The benefits manager of this prescription
reasonable alternatives. For example, we drug program has established payment
may, at our discretion, temporarily waive arrangements with participating pharmacies
your payment obligation on a qualifying that may result in savings.
prescription drug purchase.

Form Number: Wellmark IA Grp/YP_ 1010 51 8FL 3VJ 8FM 3VK

 Factors Affecting What You Pay

Medical Benefits and Prescription Drug Plan

forwarded to us by the pharmacy benefits
Wellmark Drug List manager unless your plan sponsor's
Most prescription drugs are covered under arrangement with us requires us to reduce
your prescription drug plan. such rebated amounts by the amount of any
Often there is more than one medication fees we paid to the pharmacy benefits
available to treat the same medical manager for the services rendered to your
condition. The Wellmark Drug List contains plan sponsor. We will not distribute these
drugs physicians recognize as medically rebate amounts to you, and rebates will not
effective for a wide range of health be considered when determining your
conditions. payment obligations.

The Wellmark Drug List was developed with

the assistance of physicians, pharmacists,
and Wellmark’s pharmacy benefits
manager. It is not a required list of
medications and physicians are not limited
to prescribing only the drugs that appear on
the list. Physicians may prescribe any
medication, and that medication will be
covered unless it is specifically excluded
under this medical benefits plan, or other
limitations apply.
To determine if a drug is on the Wellmark
Drug List, ask your physician, pharmacist,
or visit our website, www.wellmark.com.
The Wellmark Drug List is subject to
change.

Pharmacy Benefits Manager

Fees and Drug Company
Rebates
Wellmark contracts with a pharmacy
benefits manager to provide pharmacy
benefits management services to its
accounts, such as your plan sponsor. Your
plan sponsor is to pay a monthly fee for
such services.
Drug manufacturers offer rebates to
pharmacy benefits managers. After your
plan sponsor has had Wellmark prescription
drug coverage for at least nine months, the
pharmacy benefits manager contracting
with Wellmark will calculate, on a quarterly
basis, your plan sponsor's use of drugs for
which rebates have been paid. Wellmark
receives these rebates. Your plan sponsor
will be credited with rebate amounts

8FL 3VJ 8FM 3VK 52 Form Number: Wellmark IA Grp/YP_ 1010

8. Coverage Eligibility and Effective Date
In addition, a child must be one of the
Who is Eligible following:
You are eligible to participate in this plan if  Under age 26.
you are a member of one of the following
 A child who is totally and permanently
groups.
disabled, physically or mentally. The
Full-time Corporate Employees: A disability must have existed before the
regular, full-time employee of Casey’s child turned age 26. In addition, the
General Stores, Inc. for at least three child must have had creditable coverage
consecutive months who is regularly without a break of 63 days or more since
scheduled to work a minimum of 35 hours turning age 26.
per week.
If a dependent child is enrolled in the plan
Spouse: A husband or wife as the result of and is physically or mentally disabled on the
a marriage that is legally recognized in your date coverage would otherwise end, the
state of residence, including common law. child's eligibility will be extended for as long
Dependents: A child is eligible under the as you are covered by this plan, the
plan member’s coverage if the child is not disability continues, and the child continues
eligible for coverage under their own (or to qualify for coverage in all aspects other
their spouse’s) employer group plan and has than age.
any of the following relationships to the You must submit proof to the plan
plan member or an enrolled spouse: administrator within 30 days of the date the
 A natural child. dependent reaches the termination age. The
 Legally adopted or placed for adoption plan may require you, at any time, to obtain
(that is, you assume a legal obligation to a physician's statement certifying the
provide full or partial support and dependent’s physical or mental disability.
intend to adopt the child). You may not participate in this plan as both
 A child for whom you have legal an employee and a dependent and your
guardianship. dependents may not participate in this plan
 A stepchild. as a dependent of more than one employee.
 A foster child. Please note: In addition to the preceding
 A natural child a court orders to be requirements, eligibility is affected by
covered. coverage enrollment events and coverage
termination events. See Coverage Change
A child who has been placed in your home Events, page 59.
for the purpose of adoption or whom you
have adopted is eligible for coverage on the Who Pays For Your Benefits
date of placement for adoption or the date
Casey’s General Stores, Inc. shares the cost
of actual adoption, whichever occurs first.
of providing benefits for you and your
Please note: You must notify us or your dependents. From time to time, Casey’s
plan sponsor if you enter into an General Stores, Inc. may adjust the amount
arrangement to provide surrogate parent of contributions required for coverage. In
services: Contact your plan sponsor or call addition, the deductibles and copayments
the Customer Service number on your ID may also change periodically. You will be
card. notified of any changes in the cost of plan
coverage before they take effect.

Form Number: Wellmark IA Grp/ELG_ 1012 53 ZY7 5AQ ZY8 5AR

 Coverage Eligibility and Effective Date

Non-Tobacco Incentive dependent(s) within 31 days of the date you

Casey’s General Stores, Inc. offers a “Non- acquire them.
tobacco Premium Incentive” to employees To enroll, log on to www.mycaseys.com
and family members who do not use tobacco (see How to Enroll, later in this section) and
products. To qualify, individuals must complete the online enrollment process
be “tobacco-free” for six months prior within the applicable time period. You may
to his/her coverage effective date. The be required to obtain and provide your
reduced premiums will be offered once per employer with a Social Security number for
year, each January, and to each new each covered dependent. If you do not
enrollee. The amount of the premium complete the online enrollment process
incentive is subject to change on an annual within three months of your hire date, or
basis and will be announced at each plan within 31 days of acquiring a new
renewal. dependent, you and your family members
To qualify, participants will be required to will not be eligible to enroll unless you do so
sign an affidavit acknowledging that: within 31 days of a subsequent special
enrollment event or qualifying change in
 He/She and his/her spouse (if covered status.
under the plan) have been tobacco-free
for six months prior to his/her effective If you have family coverage, you should
date of coverage and/or plan renewal notify your employer of any newborn
date. children. However, your newborn child will
automatically be covered if the plan
 Casey’s/Wellmark has access to medical
administrator receives a medical claim for
records to check his/her tobacco use
the newborn and you pay any required
status.
contribution. If you do not pay the required
 He/She understands that providing false contribution, the newborn’s coverage will
information is illegal and subject to terminate at the end of the 31st day following
prosecution. birth.
When Coverage Begins If you have single coverage, your newborn
child will be automatically covered at birth
Eligibility Date through the first 31 days. To continue
Coverage is available on the first day of the coverage for the newborn beyond 31 days,
month following three consecutive months you must notify your employer of the birth
of active, full-time employment. Coverage and pay any required contribution. If you do
will not begin unless you are actively at not pay the required contribution, the
work, and have properly enrolled. newborn’s coverage will terminate at the
Dependent coverage begins the later of your end of the 31st day following birth.
coverage start date or the first day the Beyond 31 days, claims for maternity
dependent is legally acquired (and properly expenses will not be considered sufficient
enrolled). notification in order for newborn coverage
to continue.
Enrollment Requirements
You must enroll for coverage within three How to Enroll
months of your hire date. If you desire Casey’s uses an online Employee Benefit
dependent coverage, you must also enroll Center, www.mycaseys.com. The Employee
any eligible dependents at this time. If you Benefits Center allows you to access benefit
do not have any eligible dependents at the information from any computer with
time of initial enrollment, but later acquire internet access at any time of the day and
eligible dependents, you must enroll the serves as a means for you to enroll in benefit
plans, make changes to existing benefits,
ZY7 5AQ ZY8 5AR 54 Form Number: Wellmark IA Grp/ELG_ 1012
 Coverage Eligibility and Effective Date

report qualifying events and update When Exclusion Period Applies

personal information. The website outlines A preexisting condition exclusion period
specifics about the cost of benefits per pay applies if the member has a preexisting
period, provides a personalized condition and:
confirmation of benefits and also contains  The member is age 19 or older.
summaries of various benefit plans. To log
 The plan member is a new employee and
on to the site, type “mycaseys” as the login.
applies for coverage when initially
To enter the secure online enrollment
eligible to enroll.
system, click the “Online Enrollment” tab at
the top of the page. The Username is the  The member enrolls as a special enrollee
first six letters of your last name, followed under a qualifying enrollment event
by the first letter of your first name, when initially eligible. See Coverage
followed by the last four digits of your social Change Events, page 59.
security number (for example, Jane Doe When a preexisting condition exclusion
would be: doej1234). The default password period applies, it begins on the enrollment
is your social security number. This is a date.
temporary password which you must
change after your first sign on. Prior Creditable Coverage
Prior creditable coverage reduces the
Preexisting Condition preexisting condition exclusion period by
Exclusion Period the amount of time you had the prior
A member age 19 or older may be required coverage provided there was no break in
to wait a specified time from your coverage of 63 days or more. For instance, if
enrollment date before benefits are available you were covered by another medical
for any medical services for a preexisting benefits plan (without a break of 63 days or
condition. No preexisting condition more) for the three-month period before
exclusion period applies to a member under your enrollment date under this medical
age 19. benefits plan, and if this plan includes a 12-
The enrollment date is the earlier of the first month preexisting condition exclusion
day of coverage or, if there is a waiting period, your preexisting condition exclusion
period, the first day of the waiting period. period would be reduced to nine months.
For late enrollees, the enrollment date is the If an eligible dependent has more prior
first day of coverage. creditable coverage than the plan member,
The preexisting condition exclusion period the dependent’s preexisting condition
is 12 consecutive months from the exclusion period is reduced by his or her
enrollment date, minus any period of prior own period of prior creditable coverage.
creditable coverage. Creditable coverage means any of the
following categories of coverage, during
Preexisting Condition
which there was no break in coverage of
A preexisting condition is an illness, injury,
more than 63 days:
medical, surgical, or other condition for
which medical advice, diagnosis, or  Group health plan (including
treatment was recommended or received government and church plans).
within the six months ending on your full-  Health insurance coverage (including
time hire date for a newly hired employee or group, individual, and short-term
the effective date of this coverage for a limited duration coverage).
special enrollee. This is the preexisting  Medicare (Part A or B of Title XVIII of
condition “look back” period. Pregnancy is the Social Security Act).
not considered a preexisting condition.

Form Number: Wellmark IA Grp/ELG_ 1012 55 ZY7 5AQ ZY8 5AR

 Coverage Eligibility and Effective Date

 Medicaid (Title XIX of the Social can obtain, without charge, a copy of such
Security Act). procedures from the plan administrator.
 Medical care for members and certain A QMCSO specifies information such as:
former members of the uniformed
services, and for their dependents  Your name and last known mailing
(Chapter 55 of Title 10, United States address.
Code).  The name and mailing address of the
 A medical care program of the Indian dependent specified in the court order.
Health Service or of a tribal  A reasonable description of the type of
organization. coverage to be provided to the
 A state health benefits risk pool. dependent or the manner in which the
 Federal Employee Health Benefit Plan (a type of coverage will be determined.
health plan offered under Chapter 89 of  The period to which the order applies.
Title 5, United States Code). A Qualified Medical Child Support Order
 A State Children’s Health Insurance cannot require that a benefits plan provide
Program (S-CHIP). any type or form of benefit or option not
 A public health plan as defined in otherwise provided under the plan, except
federal regulations (including health as necessary to meet requirements of Iowa
coverage provided under a plan Code Chapter 252E (2001) or Social
established or maintained by a foreign Security Act Section 1908 with respect to
country or political subdivision). group health plans.
 A health benefits plan under Section The order and the notice given by the plan
5(e) of the Peace Corps Act. sponsor will provide additional information,
You have the right to request certification of including actions that you and the
creditable coverage from the carrier or appropriate insurer must take to determine
administrator of your prior coverage. Other the dependent’s eligibility and procedures
types of coverage besides a group health for enrollment in the benefits plan, which
plan may qualify as prior creditable must be done within specified time limits.
coverage. If eligible, the dependent will have the same
coverage as you or your spouse do and will
be allowed to enroll immediately. You or
your spouse’s plan sponsor will withhold
Qualified Medical Child any applicable share of the dependent’s
Support Order health care premiums from your
If you have a dependent child and you or compensation and forward this amount to
your spouse’s plan sponsor receives a us.
Medical Child Support Order recognizing
If you are subject to a waiting period that
the child’s right to enroll in this group
expires more than 90 days after the insurer
health plan or in your spouse’s benefits
receives the QMCSO, your plan sponsor
plan, the plan sponsor will promptly notify
must notify us when you become eligible for
you or your spouse and the dependent that
enrollment. Enrollment of the dependent
the order has been received. The plan
will commence after you have satisfied the
sponsor also will inform you or your spouse
waiting period.
and the dependent of its procedures for
determining whether the order is a The dependent may designate another
Qualified Medical Child Support Order person, such as a custodial parent or legal
(QMCSO). Participants and beneficiaries guardian, to receive copies of explanations
of benefits, checks, and other materials.

ZY7 5AQ ZY8 5AR 56 Form Number: Wellmark IA Grp/ELG_ 1012

 Coverage Eligibility and Effective Date

Your plan sponsor may not revoke

enrollment or eliminate coverage for a
dependent unless the plan 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 plan sponsor is not required to

maintain the dependent’s coverage if:
 You or your spouse no longer pay
premiums because the plan 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_ 1012 57 ZY7 5AQ ZY8 5AR

9. Coverage Changes and Termination
Certain events may require or allow you to the plan receives a QMCSO; you, your
add or remove persons who are covered by spouse or your child becomes entitled to
this group health plan. either Medicaid or Medicare; you, your
spouse or your child lose eligibility for
Coverage Change Events coverage under Medicaid or the Children’s
You are allowed to change your enrollment Health Insurance Program (CHIP) (the
elections during a benefit year if you hawk-i plan in Iowa); or you, your spouse or
experience a change in status. If you your child become eligible for premium
experience a qualifying change in your assistance under Medicaid or CHIP.
status, you may change your enrollment A qualifying change in status may also
election, but you must do so within 31 days include significant cost increases in your
of the change in status by: health coverage premiums. If your health
 Completing a change form. You may coverage premiums increases significantly
access this change form on during a Plan Year, then you may either pay
www.mycaseys.com (see How to the increase in the premium or revoke your
Enroll, page 54). coverage election and receive coverage
 Submitting any required supporting under another plan option that provides
documentation to verify the event. similar coverage. The Plan Administrator, in
 Making the necessary changes by using its sole discretion, will decide whether the
the online enrollment system. premium increase is significant, and what
constitutes “similar coverage” based upon
Any change in enrollment election must be the facts and circumstances.
consistent with your change in status. That
Qualifying Promotion Event
is, you may only change your election if the
The plan will permit an employee who is
change in status causes you or your
eligible, but not enrolled, to enroll for
dependents to gain or lose eligibility for
coverage or add eligible family members
coverage under this or another plan. The
under the terms of this plan, if each of the
election change must correspond with the
following should occur:
effect on coverage.
 The employee has satisfied the three
Qualifying Change in Status month waiting period and declined
A qualifying change in status includes: coverage when offered.
marriage; divorce; legal separation;  For Store Operations personnel, a
annulment of marriage; death of spouse or promotion from an hourly position to a
child; birth, adoption or placement of a salary position or to a qualified position
child for adoption; termination or wherein management/supervisory
commencement of employment by you, your responsibilities have commenced or
spouse or your child; a reduction or increase increased. The position levels for Store
in hours of employment for you, your Operations personnel include the
spouse or your child, including a switch following tiers. Based on these tiers, a
between part-time and full-time, a strike, promotion event for Store Operations
lockout, or commencement or return from personnel would include a promotion to
an unpaid leave of absence; a change in a position at a higher tier than was
dependent status for your child; a special previously held.
enrollment event under the Health
Insurance Portability and Accountability Act Tier 1: Store Employee/Pizza Delivery
(HIPAA) for you or your dependents; you or Driver/Car Wash Employee
Form Number: Wellmark IA Grp/CC_ 1012 59 ZY7 5AQ ZY8 5AR
 Coverage Changes and Termination

Tier 2: 2nd Assistant Manager Special Enrollment Events

Tier 3: Assistant Manager/Food Service If you decline coverage under this plan for
Manager/Pizza Delivery Team yourself or your dependents because of
Leader/Car Wash Operational Manager other health plan coverage, you must log on
Tier 4: Store Manager/Car Wash to www.mycaseys.com (see How to Enroll,
General Manager page 54) and indicate that you are declining
Tier 5: Area Supervisor coverage due to the existence of other
Tier 6: District Manager coverage.
Tier 7: Regional Manager If such other health plan coverage is
 For Non-Store Operations personnel, subsequently terminated due to a loss of
the employee is promoted from a non- eligibility for such coverage (loss of
supervisory position to a eligibility does not include a loss due to:
supervisory/management position, or to failure to pay premiums when due; failure
a position considered as non-lateral to exhaust COBRA continuation coverage, if
based on Company standards. elected; or causes such as making a
 Under the terms of the plan, the fraudulent claim or misrepresentation); or
employee requests enrollment into this termination of any company contributions
plan not later than 31 days after the date for such coverage, then you and or your
of the promotion. eligible dependents may enroll in this plan.
To enroll, you must notify your employer
For an eligible employee who has met each
and complete and log on to
of these conditions, coverage will be
www.mycaseys.com (see How to Enroll,
effective on the first day of the month
page 54) and complete the online
following the date the online enrollment
enrollment process within 31 days of the
process is complete. The eligible employee
termination of the other health plan
will be subject to any applicable preexisting
coverage.
condition exclusion period when their
coverage becomes effective, including In addition, if you acquire a new dependent
application of any creditable coverage. as a result of marriage, birth, adoption, or
placement for adoption, you and/or your
Changing Plan Options eligible dependents may enroll in this plan.
If you experience a qualifying change in To enroll, you must notify your employer
status, you can elect to change from the and complete the online enrollment process
Premium Plan to the Standard Plan or to within 31 days of the date of the marriage,
the High Deductible Health Plan, to change birth, adoption, or placement for adoption.
from the Standard Plan to the Premium or Newborns, adopted children, and children
to the High Deductible Health Plan or placed for adoption are covered retroactive
change from the High Deductible Health to the date of birth, adoption, or placement
Plan to the Standard Plan or to the for adoption.
Premium Plan. To do so, you must complete
and return any required forms within 31 Late Enrollees
days of the qualifying change in status. The
If you do not enroll within 31 days of your
plan option change will be effective on the
eligibility date or a special enrollment event,
first of the month following the date the
you and your dependents will not be eligible
change is received by Casey’s Human
to enroll unless you experience a qualifying
Resources.
change in status as outlined in earlier in this
section.

ZY7 5AQ ZY8 5AR 60 Form Number: Wellmark IA Grp/CC_ 1012

 Coverage Changes and Termination

Requirement to Notify Plan  For service of less than 31 days, no

Sponsor later than the beginning of the first
full regularly scheduled work period
You must notify your plan sponsor within 31
on the first full calendar day
days of most events that change the
following the completion of the
coverage status of members and within 60
period of service and the expiration
days of events related to Medicaid or CHIP
of eight hours after a period allowing
eligibility. If you do not provide timely
for the safe transportation from the
notification of an event that requires you to
place of service to the covered
remove an affected family member, your
employee's residence or as soon as
coverage may be terminated.
reasonably possible after such eight
The Uniformed Services hour period;
 For service of more than 30 days but
Employment and
less than 181 days, no later than 14
Reemployment Rights Act of days after the completion of the
1994 (USERRA) period of service or as soon as
Your group health plan will fully comply reasonably possible after such
with the Uniformed Services Employment period;
and Reemployment Rights Act of 1994  For service of more than 180 days,
(USERRA). If any part of the plan conflicts no later than 90 days after the
with USERRA, the conflicting provision will completion of the period of service;
not apply. All other benefits and exclusions or
of the group health plan will remain  For a covered employee who is
effective to the extent there is no conflict hospitalized or convalescing from an
with USERRA. illness or injury incurred in or
USERRA provides for, among other aggravated during the performance
employment rights and benefits, of service in the uniformed services,
continuation of health care coverage to a at the end of the period that is
covered employee and the employee’s necessary for the covered employee
covered dependents during a period of the to recover from the illness or injury.
employee’s active service or training with The period of recovery may not
any of the uniformed services. The plan exceed two (2) years.
provides that a covered employee may elect
A covered employee who elects to continue
to continue coverages in effect at the time
health plan coverage under the plan during
the employee is called to active service. The
a period of active service in the uniformed
maximum period of coverage for an
services may be required to pay no more
employee and the covered employee’s
than 102% of the full premium under the
dependents under such an election shall be
plan associated with the coverage for the
the lesser of:
employer's other employees. This is true
 The 24-month period beginning on the except in the case of a covered employee
date on which the covered employee's who performs service in the uniformed
absence begins; or services for less than 31 days. When this is
 The period beginning on the date on the case, the covered employee may not be
which the covered employee’s absence required to pay more than the employee’s
begins and ending on the day after the share, if any, for the coverage. Continuation
date on which the covered employee coverage cannot be discontinued merely
fails to apply for or return to a position because activated military personnel receive
of employment as follows: health coverage as active duty members of
the uniformed services and their family

Form Number: Wellmark IA Grp/CC_ 1012 61 ZY7 5AQ ZY8 5AR

 Coverage Changes and Termination

members are eligible to receive coverage Also see Fraud or Intentional

under the TRICARE program (formerly Misrepresentation of Material Facts, and
CHAMPUS). Nonpayment later in this section.
When a covered employee’s coverage under When Coverage Ends
a health plan was terminated by reason of Your coverage ends the earliest of: the end
service in the uniformed services, the of the month in which your employment
preexisting condition exclusion and waiting with Casey’s General Stores, Inc. ends; the
period may not be imposed in connection end of the month for which a contribution
with the reinstatement of the coverage upon was made; the end of the month in which
reemployment under USERRA. This applies you are no longer eligible to participate in
to a covered employee who is reemployed this plan; the end of the month in which you
and any dependent whose coverage is are laid off; or the date this plan terminates
reinstated. The waiver of the preexisting or is amended to terminate coverage for a
condition exclusion shall not apply to illness class of employees of which you are a
or injury which occurred or was aggravated member.
during performance of service in the
uniformed services. Coverage for your dependents ends the
earliest of: the date your coverage ends; the
Uniformed services includes full-time and end of the month in which a dependent no
reserve components of the United States longer meets the eligibility requirements;
Army, Navy, Air Force, Marines and Coast the end of the last pay period for which a
Guard, the Army National Guard, the contribution was made; or the date this plan
commissioned corps of the Public Health terminates.
Service, and any other category of persons
designated by the President in time of war If you are an inpatient of a hospital or a
or emergency. resident of a nursing facility on the date
your coverage eligibility terminates, benefits
If you are a covered employee called to a for inpatient services are limited to the least
period of active service in the uniformed amount of the following:
service, you should check with the plan
administrator for a more complete  The period of your remaining days of
explanation of your rights and obligations coverage under this medical benefits
under USERRA. plan.
 The period ending on the date you are
Coverage Termination discharged from the facility.
The following events terminate your  A period not more than 60 days from
coverage eligibility. the date of termination.
 You become unemployed when your Medical Leave
eligibility is based on employment.
If you are on an approved medical leave of
 You become ineligible under your absence, eligibility may continue for 90 days
employer’s or group sponsor’s eligibility following the date the leave began if you pay
requirements for reasons other than any required contributions toward the cost
unemployment. of the coverage. Coverage continued under
 Your plan sponsor discontinues or this provision is in addition to coverage
replaces this group health plan. continued under Optional Continuation of
 We terminate coverage of all similar Coverage (COBRA).
group health plans by written notice to
Worker’s Compensation
your plan sponsor 90 days prior to
termination. If you are unable to work full-time due to a
workers’ compensation injury, eligibility

ZY7 5AQ ZY8 5AR 62 Form Number: Wellmark IA Grp/CC_ 1012

 Coverage Changes and Termination

may continue for 90 days following the date Fraud or Intentional

the leave began if you pay any required Misrepresentation of Material Facts
contributions toward the cost of the Your coverage will terminate immediately if:
coverage. Coverage continued under this  You use this group health plan
provision is in addition to coverage fraudulently or intentionally
continued under Optional Continuation of misrepresent a material fact in your
Coverage (COBRA). application; or
Store Replacement/Remodel  Your plan sponsor commits fraud or
intentionally misrepresents a material
If you are temporarily laid off due to a store
fact under the terms of this group health
replacement or remodeling, eligibility may
plan.
continue for 90 days following the date the
layoff began if you pay any required If your coverage is terminated for fraud or
contributions toward the cost of the intentional misrepresentation of a material
coverage. Coverage continued under this fact, then:
provision is in addition to coverage
continued under Optional Continuation of  We may declare this group health plan
Coverage (COBRA). void retroactively from the effective date
of coverage following a 30-day written
Reinstatement of Coverage notice. In this case, we will recover any
If you terminate employment or lose eligible claim payments made.
coverage under this plan and elect to  Premiums may be retroactively adjusted
continue coverage under Optional as if the fraud or intentionally
Continuation of Coverage (COBRA) while misrepresented material fact had been
making the applicable contributions during accurately disclosed in your application.
the time you remain off work, the three  We will retain legal rights, including the
month waiting period will be waived when right to bring a civil action.
you regain full-time employment with the
Casey’s General Stores, Inc. However, it is Nonpayment
the employee’s responsibility immediately Your coverage will terminate immediately if
upon return to active, full-time employment you or your plan sponsor fails to make
to contact Human Resources and request required payments to us when due.
reinstatement of coverage. If your 18-month
continuation period under Optional Certificate of Creditable
Continuation of Coverage (COBRA) is Coverage
exhausted and you are later rehired, you Wellmark will provide certification of your
must again satisfy the three month waiting coverage under this medical benefits plan if:
period. The preexisting condition exclusion
 This coverage terminates.
period and all accumulated benefit year and
 You become eligible for COBRA
lifetime benefits maximums will apply.
coverage.
If you terminate employment or lose eligible  You exhaust your COBRA coverage.
coverage under this plan and elect not to
 You request certification of your
continue coverage under Optional
coverage within 24 months after this
Continuation of Coverage (COBRA), you
coverage terminates. See Notice, page
must satisfy the three month waiting period
92.
beginning from the date you return to active
full-time status. The preexisting condition
exclusion period and all accumulated
benefit year and lifetime benefits
maximums will apply.

Form Number: Wellmark IA Grp/CC_ 1012 63 ZY7 5AQ ZY8 5AR

 Coverage Changes and Termination

Coverage Continuation The following are recognized qualifying

When your coverage ends, you may be events that will entitle you, your spouse,
eligible to continue coverage under this and/or your dependent child(ren) for
group health plan. COBRA Coverage.
You will be entitled to elect COBRA:
COBRA Continuation
COBRA continuation coverage is a  If you lose your group health coverage
temporary extension of group health under the plan because your hours of
coverage under the plan under certain employment are reduced; or
circumstances when coverage would  Your employment ends for any reason
otherwise end. The right to COBRA other than your gross misconduct.
coverage was created by a federal law, the
Consolidated Omnibus Budget Your spouse will be entitled to elect COBRA
Reconciliation Act of 1985 (COBRA). if he/she loses his/her group health
COBRA coverage can become available coverage under the plan because any of the
when you would otherwise lose group health following qualifying events happens:
coverage under the plan. It can also become  You die;
available to your spouse and dependent  Your hours of employment are reduced;
children, if they are covered under the plan,
 Your employment ends for any reason
when they would otherwise lose their group
other than your gross misconduct;
health coverage under the plan. The
 You become entitled to Medicare
following paragraphs generally explain
benefits (Part A, Part B or both) prior to
COBRA coverage, when it may become
your qualifying event; or
available to you and your family, and what
you need to do to protect the right to receive  Your spouse becomes divorced or legally
it. separated from you.

The description of COBRA coverage Your dependent child will be entitled to

contained here applies only to the group elect COBRA if he/she loses his/her group
health plan benefits offered under the plan health coverage under the plan because any
and not to any other benefits offered by your of the following qualifying events happens:
plan sponsor (such as life insurance,  You die;
disability, or accidental death or
 Your hours of employment are reduced;
dismemberment benefits). The plan
provides no greater COBRA rights than  Your employment ends for any reason
what COBRA requires. Nothing in the plan other than your gross misconduct;
is intended to expand the participant’s  You become entitled to Medicare
rights beyond COBRA’s requirements. benefits (Part A, Part B or both);
 You and your spouse become divorced
Coverage Entitlement. You, your spouse,
or legally separated; or
and/or your dependent child(ren) will be
entitled to elect COBRA if you lose your  The dependent stops being eligible for
group health coverage under the plan coverage under the plan as a dependent
because of a life event known as a child.
qualifying event. You may be entitled to A child born to, adopted by, or placed for
continue this coverage under COBRA for a adoption with you during a period of
period of 18, 29, or 36 months depending on COBRA coverage is considered to be a
the qualifying event that causes loss of qualified beneficiary provided that, if you
coverage under this plan. See Length of are a qualified beneficiary, you have elected
Coverage later in this section. COBRA coverage for yourself. The child’s
COBRA coverage begins when the child is

ZY7 5AQ ZY8 5AR 64 Form Number: Wellmark IA Grp/CC_ 1012

 Coverage Changes and Termination

enrolled under this plan, whether through plan who is a qualified beneficiary. You,
special enrollment or open enrollment, and your spouse, and your dependent children
it lasts for as long as COBRA coverage lasts could become qualified beneficiaries and
for other family members of the employee. would be entitled to elect COBRA if
To be enrolled under this plan, the child coverage under the plan is lost because of
must satisfy the otherwise applicable the qualifying event.
eligibility requirements (for example,
COBRA coverage is the same coverage that
regarding age).
this plan gives to other participants or
Your child who is receiving benefits under beneficiaries under the plan who are not
this plan pursuant to a qualified medical receiving COBRA coverage. Each qualified
child support order (QMCSO) received by beneficiary who elects COBRA will have the
your plan sponsor during your period of same rights under the plan as other
employment with your plan sponsor is participants or beneficiaries covered under
entitled to the same rights to elect COBRA the component or components of this plan
as your eligible dependent child. elected by the qualified beneficiary,
including open enrollment and special
If you take a Family and Medical Leave Act
enrollment rights. Under this plan, qualified
(FMLA) leave and do not return to work at
beneficiaries who elect COBRA must pay for
the end of the leave or terminate coverage
COBRA coverage.
during the leave, you (and your spouse and
dependent children, if any) will be entitled When the qualifying event is the end of your
to elect COBRA if: employment, your reduction of hours of
employment, or your death, COBRA
 They were covered under the plan on the
coverage will be offered to qualified
day before the FMLA leave began or
beneficiaries. You need not notify your plan
became covered during the FMLA leave;
sponsor of any of these three qualifying
and
events.
 They will lose coverage under the plan
because of your failure to return to work For the other qualifying events, a COBRA
at the end of the leave. This means that election will be available only if you notify
some individuals may be entitled to elect your plan sponsor in writing within 60 days
COBRA at the end of an FMLA leave after the later of:
even if they were not covered under the  The date of the qualifying event; and
plan during the leave.
 The date on which the qualified
COBRA coverage elected in these beneficiary loses (or would lose)
circumstances will begin on the last day of coverage under the terms of the plan as
the FMLA leave, with the same 18-month a result of the qualifying event.
maximum coverage period, subject to
The written notice must include the plan
extension or early termination, generally
name or group name, your name, your
applicable to the COBRA qualifying events
Social Security Number, your dependent’s
of termination of employment and
name and a description of the event.
reduction of hours. For information on how
long you may have COBRA coverage, see Please note: If these procedures are not
later in this section, under Length of followed or if the written notice is not
Coverage. provided to your plan sponsor during the
60-day notice period, you or your
Qualifying Events. After a qualifying
dependents will lose your right to elect
event occurs and any required notice of that
COBRA.
event is properly provided to your plan
sponsor, COBRA coverage must be offered Electing Coverage. To elect COBRA, you
to each person losing coverage under the must complete the Election form that is part
Form Number: Wellmark IA Grp/CC_ 1012 65 ZY7 5AQ ZY8 5AR
 Coverage Changes and Termination

of the COBRA election notice and submit it not preserve COBRA rights: oral
to Leavex. An election notice will be communications regarding COBRA
provided to qualified beneficiaries at the coverage, including in-person or telephone
time of a qualifying event. You may also statements about an individual’s COBRA
obtain a copy of the Election form from your coverage; and electronic communications,
plan sponsor. Under federal law, you must including e-mail and faxed
have 60 days after the date the qualified communications.
beneficiary coverage under the plan
The election must be postmarked 60 days
terminates, or, if later, 60 days after the
from the termination date or 60 days from
date of the COBRA election notice provided
the date the COBRA election notice
to you at the time of the qualifying event to
provided at the time of the qualifying event.
decide whether you want to elect COBRA
Please note: If you do not submit a
under the plan.
completed Election form within this period,
Mail the completed Election form to: you will lose your right to elect COBRA.
Leavex If you reject COBRA before the due date,
COBRA Department you may change your mind as long as you
PO Box 385042 furnish a completed Election form before
Minneapolis, MN 55438 the due date. The plan will only provide
continuation coverage beginning on the date
Special Second Election Period for
the waiver of coverage is revoked.
Certain Eligible Individuals Who Did
Not Elect COBRA Coverage. Special You do not have to send any payment with
COBRA rights apply to certain employees your Election form when you elect COBRA.
who are eligible for the health coverage tax Important additional information about
credit. These employees are entitled to a payment for COBRA coverage is included
second opportunity to elect COBRA below.
coverage for themselves and certain family Each qualified beneficiary will have an
members (if they did not already elect independent right to elect COBRA. For
COBRA coverage) during a special second example, your spouse may elect COBRA
election period. This special second election even if you do not. COBRA may be elected
period lasts for 60 days or less. It is the 60- for only one, several, or for all dependent
day period beginning on the first day of the children who are qualified beneficiaries. You
month in which an employee becomes and your spouse (if your spouse is a
eligible for the health coverage tax credit, qualified beneficiary) may elect COBRA on
but only if the election is made within the behalf of all of the qualified beneficiaries,
six months immediately after the eligible and parents may elect COBRA on behalf of
employee's group health plan coverage their children. Any qualified beneficiary for
ended. If you qualify or may qualify for the whom COBRA is not elected within the 60-
health coverage tax credit, contact your day election period specified in the COBRA
(former) employer for additional election notice will lose his or her right to
information. You must contact your elect COBRA coverage.
(former) employer promptly after
qualifying for the health coverage tax When you complete the Election form, you
credit or you will lose your special must notify Leavex if any qualified
COBRA rights. beneficiary has become entitled to Medicare
(Part A, Part B, or both) and, if so, the date
The Election form must be completed in of Medicare entitlement. If you become
writing and mailed to the individual and entitled to Medicare (or first learn that you
address specified above. The following are are entitled to Medicare) after submitting
not acceptable as COBRA elections and will the Election form, immediately notify

ZY7 5AQ ZY8 5AR 66 Form Number: Wellmark IA Grp/CC_ 1012

 Coverage Changes and Termination

Leavex of the date of the Medicare COBRA coverage for the maximum time
entitlement at the address specified above available. Finally, you should take into
for delivery of the Election form. account that you have special enrollment
rights under federal law. You have the right
Qualified beneficiaries may be enrolled in
to request special enrollment in another
one or more group health components at
group health plan for which you are
the time of a qualifying event. If a qualified
otherwise eligible (such as coverage
beneficiary is entitled to a COBRA election
sponsored by the spouse’s employer) within
as the result of a qualifying event, he or she
30 days after your group health coverage
may elect COBRA under any or all of the
under the plan ends because of one of the
group health components under which he or
qualifying events listed above. You will also
she was covered on the day before the
have the same special enrollment right at
qualifying event. For example, if a qualified
the end of COBRA coverage if you get
beneficiary was covered under the medical
COBRA coverage for the maximum time
and vision components on the day before a
available.
qualifying event, he or she may elect
COBRA under the vision component only, Length of Coverage. When coverage is
the medical component only, or under both lost due to your death, your divorce or legal
medical and vision (only if both components separation, or your dependent child losing
are available as a separate election option to eligibility as a dependent child, COBRA
the active employee). coverage can last for up to a maximum of 36
months.
Qualified beneficiaries who are entitled to
elect COBRA may do so even if they have When coverage is lost due to the end of your
other group health plan coverage or are employment or reduction in hours of
entitled to Medicare benefits on or before employment, and you became entitled to
the date on which COBRA is elected. Medicare benefits less than 18 months
However, a qualified beneficiary’s COBRA before the qualifying event, COBRA
coverage will terminate automatically if, coverage for qualified beneficiaries (other
after electing COBRA, he or she becomes than you as the employee) who lose
entitled to Medicare benefits or becomes coverage as a result of the qualifying event
covered under other group health plan can last a maximum of 36 months after the
coverage (but only after any applicable date of Medicare entitlement. For example,
preexisting condition exclusions of that if you become entitled to Medicare eight
other plan have been exhausted or months before the date on which your
satisfied). For information on when employment terminates, COBRA coverage
coverage will terminate, see later in this under the plan for your spouse and children
section, under Termination of Coverage. who lost coverage as a result of your
termination can last up to 36 months after
When considering whether to elect COBRA,
the date of Medicare entitlement, which is
you should take into account that a failure
equal to 28 months after the date of the
to elect COBRA will affect your future rights
qualifying event (36 months minus eight
under federal law. First, you can lose the
months). This COBRA coverage period is
right to avoid having preexisting condition
available only if you become entitled to
exclusions applied by other group health
Medicare within 18 months before the
plans if you have a 63-day gap in health
termination or reduction of hours.
coverage, and election of COBRA may help
not have such a gap. Second, you will lose Otherwise, when coverage is lost due to the
the guaranteed right to purchase individual end of your employment or reduction of
health insurance policies that do not impose hours of employment, COBRA coverage
such preexisting condition exclusions if you generally can last for only up to a maximum
elect COBRA coverage and do not exhaust of 18 months.

Form Number: Wellmark IA Grp/CC_ 1012 67 ZY7 5AQ ZY8 5AR

 Coverage Changes and Termination

Extending Coverage. If the qualifying

The written notice must include the plan
event that resulted in your COBRA election
name or group name, your name, your
was your termination of employment or
Social Security Number, your dependent’s
reduction of hours, an extension of the
name and a description of the event.
maximum period of coverage may be
available if a qualified beneficiary is You must also provide this notice within 60
disabled or a second qualifying event days after your termination of employment
occurs. You must notify your plan sponsor or reduction of hours in order to be entitled
of a disability or a second qualifying event in to a disability extension.
order to extend the period of COBRA If these procedures are not followed or if the
coverage. Failure to provide notice of a written notice is not provided to your plan
disability or second qualifying event will sponsor during the 60-day notice period,
eliminate the right to extend the period of then there will be no disability extension of
COBRA coverage. Along with the notice of a COBRA coverage.
disability, the qualified beneficiary must
also supply a copy of the Social Security An extension of coverage will be available to
Administration disability determination. your spouse and dependent children who
are receiving COBRA coverage if a second
If a qualified beneficiary is determined by qualifying event occurs during the 60 days
the Social Security Administration to be (or, in the case of a disability extension, the
disabled and you notify your plan sponsor in 29 months) following your termination of
a timely fashion, all of the qualified employment or reduction of hours. The
beneficiaries in your family may be entitled maximum amount of COBRA coverage
to receive up to an additional 11 months of available when a second qualifying event
COBRA coverage, for a total maximum of 29 occurs is 36 months. Such second qualifying
months. This extension is available only for events may include your death, your divorce
qualified beneficiaries who are receiving or legal separation, or a dependent child’s
COBRA coverage because of a qualifying ceasing to be eligible for coverage as a
event that was your termination of dependent under this plan. These events can
employment or reduction of hours. The be a second qualifying event only if they
qualified beneficiary must be determined would have caused the qualified beneficiary
disabled at any time during the first 60 days to lose coverage under the plan if the first
of COBRA coverage. Each qualified qualifying event had not occurred. (This
beneficiary will be entitled to the disability extension is not available under this plan
extension if one of them qualifies. when you become entitled to Medicare.)
The disability extension is available only if This extension due to a second qualifying
you notify your plan sponsor in writing of event is available only if the participant
the Social Security Administration’s notifies your plan sponsor in writing of the
determination of disability within 60 days second qualifying event within 60 days after
after the latest of: the later of:
 The date of the Social Security  The date of the second qualifying event;
Administration’s disability and
determination;
 The date on which the qualified
 The date of your termination of beneficiary would lose coverage under
employment or reduction of hours; or the terms of this plan as a result of the
 The date on which the qualified second qualifying event (if it had
beneficiary loses (or would lose) occurred while the qualified beneficiary
coverage under the terms of the plan as was still covered under this plan).
a result of your termination of
employment or reduction of hours.
ZY7 5AQ ZY8 5AR 68 Form Number: Wellmark IA Grp/CC_ 1012
 Coverage Changes and Termination

If these procedures are not followed or if the coverage of a beneficiary not receiving
written notice is not provided to your plan COBRA coverage, such as fraud.
sponsor during the 60-day notice period,
there will be no extension of COBRA You must notify your plan sponsor in
coverage due to a second qualifying event. writing within 30 days if, after electing
COBRA, a qualified beneficiary becomes
In addition to the regular COBRA entitled to Medicare (Part A, Part B, or
termination events specified later in this both) or becomes covered under other
section, the disability extension period will group health plan coverage. This is true only
end the first of the month beginning more after any preexisting condition exclusions of
than 30 days following recovery. that other plan for a preexisting condition of
For example, if disability ends June 10, the qualified beneficiary have been
coverage will continue through the month of exhausted or satisfied.
July (7/31). COBRA coverage will terminate
Termination of Coverage. Coverage (retroactively if applicable) as of the date of
under COBRA will end when you meet the Medicare entitlement or as of the beginning
maximum period for your qualifying event, date of the other group health coverage
as indicated earlier under Length of (after exhaustion or satisfaction of any
Coverage. preexisting condition exclusions for a
preexisting condition of the qualified
COBRA coverage will automatically beneficiary). Your plan sponsor will require
terminate before the end of the maximum repayment of all benefits paid after the
period if: termination date, regardless of whether or
 Any required premium is not paid in full when you provide notice to your plan
on time; sponsor of Medicare entitlement or other
 A qualified beneficiary becomes covered, group health plan coverage.
after electing COBRA, under another If a disabled qualified beneficiary is
group health plan (but only after any determined by the Social Security
preexisting condition exclusions of that Administration to no longer be disabled,
other plan for a preexisting condition of you must notify your plan sponsor of that
the qualified beneficiary have been fact within 30 days after the Social Security
exhausted or satisfied); Administration’s determination.
 A qualified beneficiary becomes entitled
If the Social Security Administration’s
to Medicare benefits (under Part A, Part
determination that the qualified beneficiary
B, or both) after electing COBRA;
is no longer disabled occurs during a
 The employer ceases to provide any disability extension period, COBRA
group health plan for its employees; or coverage for all qualified beneficiaries will
 During a disability extension period, the terminate (retroactively if applicable) as of
disabled qualified beneficiary is the first day of the month that is more than
determined by the Social Security 30 days after the Social Security
Administration to be no longer disabled. Administration’s determination that the
For more information about the qualified beneficiary is no longer disabled.
disability extension period, see Your plan sponsor will require repayment of
Extending Coverage, earlier in this all benefits paid after the termination date,
section. regardless of whether or when you provide
 COBRA coverage may also be notice to your plan sponsor that the
terminated for any reason this plan disabled qualified beneficiary is no longer
would terminate your coverage or disabled. For more information about the

Form Number: Wellmark IA Grp/CC_ 1012 69 ZY7 5AQ ZY8 5AR

 Coverage Changes and Termination

disability extension period, see Extending under the plan would have otherwise
Coverage, earlier in this section. terminated up through the end of the month
before the month in which you make your
Coverage Cost and Payment. Each
first payment.
qualified beneficiary is required to pay the
entire cost of COBRA coverage. The amount For example, Sue’s employment terminated
a qualified beneficiary may be required to on September 30, and she loses coverage on
pay may not exceed 102 percent (or, in the September 30. Sue elects COBRA on
case of an extension of COBRA coverage due November 15. Her initial premium payment
to a disability, 150 percent) of the cost to the equals the premiums for October and
group health plan (including both employer November and is due on or before
and employee contributions) for coverage of December 30, the 45th day after the date of
a similarly situated plan participant or her COBRA election.
beneficiary who is not receiving COBRA
You are responsible for making sure that the
coverage. The amount of the COBRA
amount of your first payment is correct. You
premiums may change from time to time
may contact the plan administrator to
during the period of COBRA coverage and
confirm the correct amount of the first
will most likely increase over time. You will
payment.
be notified of COBRA premium changes.
Claims for reimbursement will not be
All COBRA premiums must be paid by
processed and paid until you have elected
check or money order.
COBRA and make the first payment for it.
Your first payment and all monthly
If you do not make the first payment for
payments for COBRA coverage must be
COBRA coverage in full within 45 days after
made payable to Leavex and mailed to:
the date of your election, you will lose all
Leavex COBRA rights under this plan.
COBRA Department
After you make your first payment for
PO Box 385042
COBRA coverage, you will be required to
Minneapolis, MN 55438
make monthly payments for each
The payment is considered to have been subsequent month of COBRA coverage. The
made on the date that it is postmarked. You amount due for each month for each
will not be considered to have made any qualified beneficiary will be disclosed in the
payment by mailing a check if your check is election notice provided at the time of the
returned due to insufficient funds or qualifying event. Under the plan, each of
otherwise. these monthly payments for COBRA
coverage is due on the first day of the month
If you elect COBRA, you do not have to send
for that month’s COBRA coverage. If you
any payment with the Election form.
make a monthly payment on or before the
However, you must make your first payment
first day of the month to which it applies,
for COBRA coverage not later than 45 days
your COBRA coverage under this plan will
after the date of election. This is the date the
continue for that month without any break.
Election form is postmarked, if mailed, or
the date the Election form is received by the Although monthly payments are due on the
individual at the address specified for first day of each month of COBRA coverage,
delivery of the Election form, if hand- you will be given a grace period of 30 days
delivered. For more information on electing after the first day of the month to make each
coverage, see Electing Coverage earlier in monthly payment. COBRA coverage will be
this section. provided for each month as long as payment
for that month is made before the end of the
The first payment must cover the cost of
grace period for that payment. However, if
COBRA coverage from the time coverage
you pay a monthly payment later than the
ZY7 5AQ ZY8 5AR 70 Form Number: Wellmark IA Grp/CC_ 1012
 Coverage Changes and Termination

first day of the month to which it applies, Notification of Changes. In order to

but before the end of the grace period for protect your family’s rights, you should keep
the month, your coverage under this plan Leavex informed of any changes in the
will be suspended as of the first day of the addresses of family members. You should
month and then retroactively reinstated also keep a copy, for your records, of any
(going back to the first day of the month) notices sent by your plan sponsor.
when the monthly payment is received. This
Plan Contact Information. For
means that any claim submitted for benefits
additional information about you and your
while coverage is suspended may be denied
dependents’ rights and obligations under
and may have to be resubmitted once
the plan and under federal law, you should
coverage is reinstated.
contact your plan sponsor, the plan
If you fail to make a monthly payment administrator. You may obtain information
before the end of the grace period for that about COBRA coverage on request from:
month, you will lose all rights to COBRA
Leavex
coverage under the plan.
COBRA Department
Health Coverage Tax Credit. The Trade PO Box 385042
Act of 2002 created a health coverage tax Minneapolis, MN 55438
credit for certain individuals who become
The contact information for the plan may
eligible for trade adjustment assistance
change from time to time. The most recent
(eligible individuals). Under the tax
information will be included in the most
provisions, eligible individuals may take a
recent plan documents (if you are not sure
tax credit or get advance payment of 72.5%
whether this is the most recent plan
of premiums paid for qualified health
document, you may request the most recent
insurance, including continuation coverage.
one from the plan administrator or your
If you have questions about these tax
plan sponsor).
provisions, you may call the Health Care
Tax Credit Customer Contact Center toll- Family and Medical Leave Act
free at 866-628-4282. TTD/TTY callers
may call toll-free at 866-626-4282. More
of 1993
information about the Trade Act is also The Family and Medical Leave Act of 1993
available at www.doleta.gov/tradeact/ (FMLA), requires a covered employer to
2002act_index.cfm. allow an employee with 12 months or more
of service who has worked for 1,250 hours
Assistance With Questions. Questions over the previous 12 months and who is
concerning the plan or your COBRA rights employed at a worksite where 50 or more
should be addressed to the contact or employees are employed by the employer
contacts identified below. For more within 75 miles of that worksite a total of 12
information about rights under ERISA, weeks of leave per fiscal year for the birth of
including COBRA, the Health Insurance a child, placement of a child with the
Portability and Accountability Act employee for adoption or foster care, care
(HIPAA), and other laws affecting group for the spouse, child or parent of the
health plans, contact the nearest Regional or employee if the individual has a serious
District Office of the U.S. Department of health condition or because of a serious
Labor’s Employee Benefits Security health condition, the employee is unable to
Administration (EBSA) or visit the EBSA perform any one of the essential functions
website at www.dol.gov/ebsa. Addresses of the employee’s regular position. In
and phone numbers of Regional and District addition, FMLA requires an employer to
EBSA Offices are also available through allow eligible employees to take up to 12
EBSA’s website. weeks of leave per 12-month period for
qualifying exigencies arising out of a
Form Number: Wellmark IA Grp/CC_ 1012 71 ZY7 5AQ ZY8 5AR
 Coverage Changes and Termination

covered family member’s active military

duty in support of a contingency operation
and to take up to 26 weeks of leave during a
single 12-month period to care for a covered
family member recovering from a serious
illness or injury incurred in the line of duty
during active service.
Any employee taking a leave under the
FMLA shall be entitled to continue the
employee’s benefits during the duration of
the leave. The employer must continue the
benefits at the level and under the
conditions of coverage that would have been
provided if the employee had remained
employed. Please note: The employee is
still responsible for paying their share of the
premium if applicable. If the employee for
any reason fails to return from the leave, the
employer may recover from the employee
that premium or portion of the premium
that the employer paid, provided the
employee fails to return to work for any
reason other than the reoccurrence of the
serious health condition or circumstances
beyond the control of the employee.
Leave taken under the FMLA does not
constitute a qualifying event so as to trigger
COBRA rights. However, a qualifying event
triggering COBRA coverage may occur when
it becomes known that the employee is not
returning to work. Therefore, if an employee
does not return at the end of the approved
period of Family and Medical Leave and
terminates employment with employer, the
COBRA qualifying event occurs at that time.
If you have any questions regarding your
eligibility or obligations under the FMLA,
contact your plan sponsor.

ZY7 5AQ ZY8 5AR 72 Form Number: Wellmark IA Grp/CC_ 1012

10. Claims
Once you receive medical services or claim form. Complete all sections of the
purchase prescription drugs from a claim form. For more efficient processing,
nonparticipating pharmacy we must receive all claims (including those completed out-
a claim to determine the amount of your of-country) should be written in English.
benefits. The claim lets us know the services
If you need assistance completing the claim
or prescription drugs you received, when
form, call the Customer Service number on
you received them, and from which
your ID card.
provider.
Medical Claim Form. Follow these steps
When to File a Claim to complete a medical claim form:
You need to file a claim if you:  Use a separate claim form for each
 Use a provider who does not file claims covered family member and each
for you. Participating and PPO providers provider.
file claims for you.  Attach a copy of an itemized statement
 Purchase prescription drugs from a prepared by your provider. We cannot
nonparticipating pharmacy. accept statements you prepare, cash
 Purchase prescription drugs from a register receipts, receipt of payment
participating pharmacy but do not notices, or balance due notices. In order
present your ID card. for a claim request to qualify for
processing, the itemized statement must
 Pay in full for a drug that you believe
be on the provider’s stationery, and
should have been covered.
include at least the following:
Your submission of a prescription to a  Identification of provider: full name,
participating pharmacy is not a filed claim address, tax or license ID numbers,
and therefore is not subject to appeal and provider numbers.
procedures as described in the Appeals  Patient information: first and last
section. However, you may file a claim with name, date of birth, gender,
us for a prescription drug purchase you relationship to plan member, and
think should have been a covered benefit. daytime phone number.
Wellmark must receive claims within 365  Date(s) of service.
days following the date of service of the  Charge for each service.
claim.  Place of service (office, hospital, etc).
 For injury or illness: date and
How to File a Claim diagnosis.
All claims must be submitted in writing.  For inpatient claims: admission

1. Get a Claim Form date, patient status, attending

Forms are available at www.wellmark.com physician ID.
or by calling the Customer Service number  Days or units of service.
on your ID card or from your personnel  Revenue, diagnosis, and procedure
department. codes.
 Description of each service.
2. Fill Out the Claim Form
Follow the same claim filing procedure
regardless of where you received services.
Directions are printed on the back of the

Form Number: Wellmark IA Grp/CL_ 1012 73 ZY7 5AQ ZY8 5AR

 Claims

Prescription Drugs Covered Under Medical Claims and Claims for Drugs
This Medical Benefits Plan Claim Covered Under This Medical Benefits
Form. For prescription drugs covered Plan. Send the claim to:
under this medical benefits plan (not
Wellmark Blue Cross and Blue Shield of
covered under the prescription drug plan),
Iowa
use a separate prescription drug claim form
1331 Grand Avenue, Station 5C139
and include the following information:
Des Moines, IA 50309-2901
 Pharmacy name and address.
Medical Claims for Services Received
 Patient information: first and last name, Outside the United States. Send the
date of birth, gender, and relationship to claim to:
plan member.
 Date(s) of service. BlueCard Worldwide Service Center
P.O. Box 72017
 Description and quantity of drug.
Richmond, VA 23255-2017
 Original pharmacy receipt or cash
receipt with the pharmacist’s signature Claims for Drugs Covered Under the
on it. Prescription Drug Plan. Send the claim
to:
Prescription Drug Claim Form. For
prescription drugs covered under the Catamaran
prescription drug plan, complete the Claims Department
following steps: P.O. Box 1069
Rockville, MD 20849-1069
 Use a separate claim form for each
covered family member and each We may require additional information
pharmacy. from you or your provider before a claim
can be considered complete and ready for
 Complete all sections of the claim form.
processing.
Include your daytime telephone
number.
Notification of Decision
 Submit up to three prescriptions for the
We will send an Explanation of Health Care
same family member and the same
Benefits (EOB) following your claim. The
pharmacy on a single claim form. Use
EOB is a statement outlining how we
additional claim forms for claims that
applied benefits to a submitted claim. It
exceed three prescriptions or if the
details amounts that providers charged,
prescriptions are for more than one
network savings, our paid amounts, and
family member or pharmacy.
amounts for which you are responsible.
 Attach receipts to the back of the claim
form in the space provided. In case of an adverse decision, the notice
will be sent within 30 days of receipt of the
3. Sign the Claim Form claim. We may extend this time by up to 15
days if the claim determination is delayed
4. Submit the Claim
for reasons beyond our control. If we do not
We recommend you retain a copy for your
send an explanation of benefits statement or
records. The original form you send or any
a notice of extension within the 30-day
attachments sent with the form cannot be
period, you have the right to begin an
returned to you.
appeal. We will notify you of the
circumstances requiring an extension and
the date by which we expect to render a
decision.

ZY7 5AQ ZY8 5AR 74 Form Number: Wellmark IA Grp/CL_ 1012

 Claims

If an extension is necessary because we

require additional information from you,
the notice will describe the specific
information needed. You have 45 days from
receipt of the notice to provide the
information. Without complete information,
your claim will be denied.
If you have other insurance coverage, our
processing of your claim may utilize
coordination of benefits guidelines. See
Coordination of Benefits, page 77.
Once we pay your claim, whether our
payment is sent to you or to your provider,
our obligation to pay benefits for the claim
is discharged. However, we may adjust a
claim due to overpayment or underpayment
for up to 18 months after we first process
the claim. In the case of nonparticipating
hospitals, M.D.’s, and D.O.’s located in
Iowa, the health plan payment is made
payable to the provider, but the check is
sent to you. You are responsible for
forwarding the check to the provider, plus
any difference between the amount charged
and our payment.

Form Number: Wellmark IA Grp/CL_ 1012 75 ZY7 5AQ ZY8 5AR

11. Coordination of Benefits
Coordination of benefits applies when you  Limited benefit health coverage, as
have more than one insurance policy or defined by Iowa law.
group health plan that provides the same or  School accident-type coverage.
similar benefits as this plan. Benefits  Benefits for non-medical components of
payable under this plan, when combined long-term care policies.
with those paid under your other coverage,
 Medicare supplement policies.
will not be more than 100 percent of either
 Medicaid policies.
our payment arrangement amount or the
other plan’s payment arrangement amount.  Coverage under other governmental
plans, unless permitted by law.
The method we use to calculate the payment
arrangement amount may be different from You must cooperate with Wellmark and
your other plan’s method. provide requested information about other
coverage. Failure to provide information can
Other Coverage result in a denied claim. We may get the
When you receive services, you must inform facts we need from or give them to other
us that you have other coverage, and inform organizations or persons for the purpose of
your health care provider about your other applying the following rules and
coverage. Other coverage includes any of the determining the benefits payable under this
following: plan and other plans covering you. We need
not tell, or get the consent of, any person to
 Group and nongroup insurance
do this.
contracts and subscriber contracts.
 HMO contracts. Your participating or PPO provider will
forward your coverage information to us. If
 Uninsured arrangements of group or
you have a nonparticipating provider, you
group-type coverage.
are responsible for informing us about your
 Group and nongroup coverage through
other coverage.
closed panel plans.
 Group-type contracts. Claim Filing
 The medical care components of long- If you know that your other coverage has
term contracts, such as skilled nursing primary responsibility for payment, after
care. you receive services, a claim should be
 Medicare or other governmental submitted to your other insurance carrier
benefits (not including Medicaid). first. If that claim is processed with an
 The medical benefits coverage of your unpaid balance for benefits eligible under
auto insurance (whether issued on a this group health plan, you or your provider
fault or no-fault basis). should submit a claim to us and attach the
other carrier’s explanation of benefit
Coverage that is not subject to coordination payment. We may contact your provider or
of benefits includes the following: the other carrier for further information.
 Hospital indemnity coverage or other
fixed indemnity coverage. Rules of Coordination
 Accident-only coverage. We follow certain rules to determine which
health plan or coverage pays first (as the
 Specified disease or specified accident
primary plan) when other coverage provides
coverage.
the same or similar benefits as this group
health plan. Here are some of those rules:
Form Number: Wellmark IA Grp/COB_ 1012 77 ZY7 5AQ ZY8 5AR
 Coordination of Benefits

 The primary plan pays or provides result, the plans do not agree on the
benefits according to its terms of order of benefits, this rule is ignored.
coverage and without regard to the  If a person whose coverage is provided
benefits under any other plan. Except as pursuant to COBRA or under a right of
provided below, a plan that does not continuation provided by state or other
contain a coordination of benefits federal law is covered under another
provision that is consistent with plan, the plan covering the person as an
applicable regulations is always primary employee, plan member, subscriber,
unless the provisions of both plans state policyholder or retiree is the primary
that the complying plan is primary. plan and the COBRA or state or other
 Coverage that is obtained by federal continuation coverage is the
membership in a group and is designed secondary plan. If the other plan does
to supplement a part of a basic package not have this rule and, as a result, the
of benefits is excess to any other parts of plans do not agree on the order of
the plan provided by the contract benefits, this rule is ignored.
holder. (Examples of such  The coverage with the earliest
supplementary coverage are major continuous effective date pays first if
medical coverage that is superimposed none of the rules above apply.
over base plan hospital and surgical  Notwithstanding the preceding rules,
benefits and insurance-type coverage when you use your prescription drug
written in connection with a closed plan ID card, the benefits of the
panel plan to provide out-of-network prescription drug plan are primary for
benefits.) prescription drugs purchased at a
 The coverage that you have as an pharmacy. Benefits of this prescription
employee, plan member, subscriber, drug plan are not available when the
policyholder, or retiree pays before pharmacy claim is paid by another plan.
coverage that you have as a spouse or  If the preceding rules do not determine
dependent. However, if the person is a the order of benefits, the benefits
Medicare beneficiary and, as a result of payable will be shared equally between
federal law, Medicare is secondary to the the plans. In addition, this plan will not
plan covering the person as a dependent pay more than it would have paid had it
and primary to the plan covering the been the primary plan.
person as other than a dependent (e.g., a
retired employee), then the order of Dependent Children
benefits between the two plans is To coordinate benefits for a dependent
reversed, so that the plan covering the child, the following rules apply (unless there
person as the employee, plan member, is a court decree stating otherwise):
subscriber, policyholder or retiree is the  If the child is covered by both parents
secondary plan and the other plan is the who are married (and not separated) or
primary plan. who are living together, whether or not
 The coverage that you have as the result they have been married, then the
of active employment (not laid off or coverage of the parent whose birthday
retired) pays before coverage that you occurs first in a calendar year pays first.
have as a laid-off or retired employee. If both parents have the same birthday,
The same would be true if a person is a the plan that has covered the parent the
dependent of an active employee and longest is the primary plan.
that same person is a dependent of a
 For a child covered by separated or
retired or laid-off employee. If the other
divorced parents or parents who are not
plan does not have this rule and, as a

ZY7 5AQ ZY8 5AR 78 Form Number: Wellmark IA Grp/COB_ 1012

 Coordination of Benefits

living together, whether or not they have If none of these rules apply to your
been married: situation, we will follow the Iowa Insurance
 If a court decree states that one of Division’s Coordination of Benefits
the parents is responsible for the guidelines to determine this health plan
child’s health care expenses or payment.
coverage and the plan of that parent
Effects on the Benefits of this Plan
has actual knowledge of those terms,
In determining the amount to be paid for
then that parent’s coverage pays
any claim, the secondary plan will calculate
first. If the parent with responsibility
the benefits it would have paid in the
has no health care coverage for the
absence of other coverage and apply the
dependent child’s health care
calculated amount to any allowable expense
expenses, but that parent’s spouse
under its plan that is unpaid by the primary
does, that parent’s spouse’s coverage
plan. The secondary plan may then reduce
pays first. This item does not apply
its payment by the amount so that, when
with respect to any plan year during
combined with the amount paid by the
which benefits are paid or provided
primary plan, total benefits paid or provided
before the entity has actual
by all plans for the claim do not exceed the
knowledge of the court decree
total allowable expense for that claim. In
provision.
addition, the secondary plan will credit to its
 If a court decree states that both
applicable deductible any amounts it would
parents are responsible for the have credited to its deductible in the
child’s health care expense or health absence of other coverage.
care coverage or if a court decree
states that the parents have joint Right of Recovery
custody without specifying that one If the amount of payments made by us is
parent has responsibility for the more than we should have paid under these
health care expenses or coverage of coordination of benefits provisions, we may
the dependent child, then the recover the excess from any of the persons
coverage of the parent whose to or for whom we paid, or from any other
birthday occurs first in a calendar person or organization that may be
year pays first. If both parents have responsible for the benefits or services
the same birthday, the plan that has provided for the covered person. The
covered the parent the longest is the amount of payments made includes the
primary plan. reasonable cash value of any benefits
 If a court decree does not specify provided in the form of services.
which parent has financial or
insurance responsibility, then the Coordination with Medicare
coverage of the parent with custody For medical claims only, Medicare is by law
pays first. The payment order for the the secondary coverage to group health
child is as follows: custodial parent, plans in a variety of situations. Please
spouse of custodial parent, other note: For a member covered by Medicare
parent, spouse of other parent. A Part A, benefits under this medical benefits
custodial parent is the parent plan will be coordinated with benefits
awarded custody by a court decree available under Medicare Part A and Part B,
or, in the absence of a court decree, even if the member is not enrolled in
is the parent with whom the child Medicare Part B. Therefore, a member
resides more than one-half of the enrolled in Medicare Part A should also
calendar year excluding any consider enrolling in Medicare Part B.
temporary visitation.

Form Number: Wellmark IA Grp/COB_ 1012 79 ZY7 5AQ ZY8 5AR

 Coordination of Benefits

The following provisions apply only if you secondary payer during the first 30 months
have both Medicare and employer group of ESRD eligibility. However, if the group
health coverage under this medical benefits health plan is secondary to Medicare (based
plan and your employer has the required on other Medicare secondary-payer
minimum number of employees. requirements) at the time the beneficiary
becomes covered for ESRD, the group
Working Aged health plan remains secondary to Medicare.
If you are a member of a group health plan
of an employer with at least 20 employees This is only a general summary of the laws,
for each working day for at least 20 calendar which may change from time to time. For
weeks in the current or preceding year, then more information, contact your employer or
Medicare is the secondary payer if the the Social Security Administration.
beneficiary is:
 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 Medicare
is the secondary payer if the beneficiary is:
 Under age 65;
 A recipient of Medicare disability
benefits; and
 A current employee or a spouse or
dependent of a current employee,
covered by an employer group health
plan.

End-Stage Renal Disease (ESRD)

The ESRD requirements apply to group
health plans of all employers, regardless of
the number of employees. Under these
requirements, Medicare is the secondary
payer during the first 30 months of
Medicare coverage if both of the following
are true:
 The beneficiary has Medicare coverage
as an ESRD patient; and
 The beneficiary is covered by an
employer group health plan.

If the beneficiary is already covered by

Medicare due to age or disability and the
beneficiary becomes eligible for Medicare
ESRD coverage, Medicare generally is the
ZY7 5AQ ZY8 5AR 80 Form Number: Wellmark IA Grp/COB_ 1012
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 or an adverse benefit determination in support of your appeal. You must also
concerning a pre-service notification submit:
requirement. Pre-service notification
 Date of your request.
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
You or your authorized representative, if For a prescription drug appeal, you
you have designated one, may appeal an also must submit:
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,
 A copy of the prescription.
www.wellmark.com. See Authorized
Representative, page 85.  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 Blue Cross and Blue Shield of
experience severe pain that cannot be Iowa
adequately controlled while you wait for a Special Inquiries
decision. P.O. Box 9232, Station 5W189
Des Moines, IA 50306-9232
Non-Medically Urgent Appeal
To appeal an adverse benefit determination Review of Internal Appeal
that is not medically urgent, you must make Your request for an internal appeal will be
your request for a review in writing. reviewed only once. The review will take
into account all information regarding the
Form Number: Wellmark IA Grp/AP_ 1012 81 ZY7 5AQ ZY8 5AR
 Appeals

adverse benefit determination whether or

not the information was presented or
available at the initial determination. Upon
request, and free of charge, you will be
provided reasonable access to and copies of
all relevant records used in making the
initial determination.
The review will not be conducted by the
original decision makers or any of their
subordinates. The review will be conducted
without regard to the original decision. If a
decision requires medical judgment, we will
consult an appropriate medical expert who
was not previously involved in the original
decision and who has no conflict of interest
in making the decision. If we deny your
appeal, in whole or in part, you may request,
in writing, the identity of the medical expert
we consulted.

Decision on Internal Appeal

The decision on appeal is the final internal
determination. Once a decision on internal
appeal is reached, your right to internal
appeal is exhausted.

Medically Urgent Appeal

For a medically urgent appeal, you will be
notified (by telephone, e-mail, fax or
another prompt method) of our decision as
soon as possible, based on the medical
situation, but no later than 72 hours after
your expedited appeal request is received. If
the decision is adverse, a written
notification will be sent.

All Other Appeals

For all other appeals, you will be notified in
writing of our decision. Most appeal
requests will be determined within 30 days
and all appeal requests will be determined
within 60 days.

Legal Action
You shall not start legal action against us
until you have exhausted the appeal
procedure described in this section.

ZY7 5AQ ZY8 5AR 82 Form Number: Wellmark IA Grp/AP_ 1012

13. 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 summary plan
to this federal law unless the benefits plan is
description and the documents governing
a governmental or church plan as defined in
the plan. See COBRA Continuation, page
ERISA.
64.
As a participant in this group health plan,
You have the right to reduced or eliminated
you are entitled to certain rights and
exclusionary periods of coverage for
protections under the Employee Retirement
preexisting conditions under your group
Income Security Act of 1974 (ERISA).
health plan, if you have creditable coverage
Receive Information About Your Plan from another plan.
and Benefits You should be provided a certificate of
You may examine, without charge, at the
creditable coverage, free of charge, from
plan administrator’s office or at other
your group health plan or health insurance
specified locations, such as worksites and
issuer when:
union halls, all documents governing the
plan, including insurance contracts and  You lose coverage under the plan.
collective bargaining agreements, and a  You become entitled to COBRA
copy of the latest annual report (Form 5500 continuation coverage.
Series) filed by the plan with the U.S.  Your COBRA continuation coverage
Department of Labor and available at the ceases, if you request it before losing
Public Disclosure Room of the Employee coverage, or if you request it up to 24
Benefits Security Administration. months after losing coverage.
You may obtain, upon written request to the Without evidence of creditable coverage,
plan administrator, copies of documents you may be subject to a preexisting
governing the operation of the plan, condition exclusion period for up to 12
including insurance contracts and collective months (up to 18 months for late enrollees)
bargaining agreements, and copies of the after your enrollment date in the coverage.
latest annual report (Form 5500 Series) and See Certificate of Creditable Coverage, page
updated summary plan description. The 63.
plan administrator may make a reasonable
charge for the copies. Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan
You may also obtain a summary of the
participants, ERISA imposes duties upon
plan’s annual financial report. The plan
the people responsible for the operation of
administrator is required by law to furnish
your employee benefits plan. The people
you with a copy of this summary annual
who operate the plan, called fiduciaries of
report.
the plan, have a duty to do so prudently and
in the interest of you and other plan
Form Number: Wellmark IA Grp/ER_ 1010 83 ZY7 5AQ ZY8 5AR
 Your Rights Under ERISA

participants and beneficiaries. No one, or about your rights under ERISA, or if you
including your employer, your union, or any need assistance in obtaining documents
other person, may fire you or otherwise from the plan administrator, you should
discriminate against you in any way to contact the nearest office of the Employee
prevent you from obtaining a welfare benefit Benefits Security Administration, U.S.
or exercising your rights under ERISA. Department of Labor, listed in the
telephone directory, or write to:
Enforcement of Rights
If your claim for a covered benefit is denied Division of Technical Assistance and
or ignored, in whole or in part, you have a Inquiries
right to know why this was done, to obtain Employee Benefits Security
copies of documents relating to the decision Administration
without charge, and to appeal any denial, all U.S. Department of Labor
within certain time schedules. 200 Constitution Avenue, N.W.
Washington, D.C. 20210
Under ERISA, there are steps you can take
to enforce the above rights. For instance, if You may also obtain certain publications
you request a copy of plan documents or the about your rights and responsibilities under
latest annual report from the plan and do ERISA by calling the publications hotline of
not receive them within 30 days, you may the Employee Benefits Security
file suit in federal court. In such a case, the Administration.
court may require the plan administrator to
provide the materials and pay you up to
$110 a day until you receive the materials,
unless the materials were not sent because
of reasons beyond the control of the plan
administrator. If you have a claim for
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

ZY7 5AQ ZY8 5AR 84 Form Number: Wellmark IA Grp/ER_ 1010

14. General Provisions
at any time. Any amendment or
Contract modification will be in writing and will be as
The conditions of your coverage are defined binding as this summary plan description. If
in your contract. Your contract includes: your contract is terminated, you may not
receive benefits.
 Any application you submitted to us or
to your plan sponsor. Authorized Group Health
Any agreement or group policy we have

Plan Changes
with your plan sponsor.
No agent, employee, or representative of
 Any application completed by your plan
ours is authorized to vary, add to, change,
sponsor.
modify, waive, or alter any of the provisions
 This summary plan description and any described in this summary plan description.
riders or amendments. This summary plan description cannot be
All of the statements made by you or your changed except by one of the following:
plan sponsor in any of these materials will  Written amendment signed by an
be treated by us as representations, not authorized officer and accepted by you
warranties. or your plan sponsor.
 Our receipt of proper notification that
Interpreting this Summary an event has changed your spouse or
Plan Description dependent’s eligibility for coverage. See
We will interpret the provisions of this Coverage Changes and Termination,
summary plan description and determine page 59.
the answer to all questions that arise under
it. We have the administrative discretion to Authorized Representative
determine whether you meet our written You may authorize another person to
eligibility requirements, or to interpret any represent you and with whom you want us
other term in this summary plan to communicate regarding specific claims or
description. If any benefit described in this an appeal. This authorization must be in
summary plan description is subject to a writing, signed by you, and include all the
determination of medical necessity, we will information required in our Authorized
make that factual determination. Our Representative Form. This form is available
interpretations and determinations are final at www.wellmark.com or by calling the
and conclusive. Customer Service number on your ID card.
There are certain rules you must follow in In a medically urgent situation your treating
order for us to properly administer your health care practitioner may act as your
benefits. Different rules appear in different authorized representative without
sections of your summary plan description. completion of the Authorized
You should become familiar with the entire Representative Form.
document.
An assignment of benefits, release of
Authority to Terminate, information, or other similar form that you
may sign at the request of your health care
Amend, or Modify provider does not make your provider an
Your plan sponsor has the authority to authorized representative. You may
terminate, amend, or modify the coverage authorize only one person as your
described in this summary plan description

Form Number: Wellmark IA Grp/GP_ 1012 85 ZY7 5AQ ZY8 5AR

 General Provisions

representative at a time. You may revoke the may disclose your health information to a
authorized representative at any time. health care provider or entity subject to the
federal privacy rules so they can obtain
Release of Information payment or engage in these payment
You have agreed in your application (or in activities.
documents kept by us or your plan sponsor)
to release any necessary information Health Care Operations
requested about you so we can process We may use and disclose your health
claims for benefits. information in connection with health care
operations. Health care operations include,
You must allow any provider, facility, or but are not limited to, determining payment
their employee to give us information about and rates for your group health plan; quality
a treatment or condition. If we do not assessment and improvement activities;
receive the information requested, or if you reviewing the competence or qualifications
withhold information in your application, of health care practitioners, evaluating
your benefits may be denied. If you provider performance, conducting training
fraudulently use your coverage or programs, accreditation, certification,
misrepresent or conceal material facts in licensing, or credentialing activities;
your application, then we may terminate medical review, legal services, and auditing,
your coverage under this group health plan. including fraud and abuse detection and
compliance; business planning and
Privacy of Information development; and business management
Your plan sponsor is required to protect the and general administrative activities.
privacy of your health information. It is
required to request, use, or disclose your Other Disclosures
health information only as permitted or Your plan sponsor or Wellmark is required
required by law. For example, your plan to obtain your explicit authorization for any
sponsor has contracted with Wellmark to use or disclosure of your health information
administer this group health plan and that is not permitted or required by law. For
Wellmark will use or disclose your health example, we may release claim payment
information for treatment, payment, and information to a friend or family member to
health care operations according to the act on your behalf during a hospitalization if
standards and specifications of the federal you submit an authorization to release
privacy regulations. information to that person.

Treatment Member Health Support

We may disclose your health information to Services
a physician or other health care provider in Wellmark may from time to time make
order for such health care provider to available to you certain health support
provide treatment to you. services (such as disease management), for
Payment a fee or for no fee. Wellmark may offer
We may use and disclose your health financial and other incentives to you to use
information to pay for covered services from such services. As a part of the provision of
physicians, hospitals, and other providers, these services, Wellmark may:
to determine your eligibility for benefits, to  Use your personal health information
coordinate benefits, to determine medical (including, but not limited to, substance
necessity, to obtain payment from your plan abuse, mental health, and HIV/AIDS
sponsor, to issue explanations of benefits to information); and
the person enrolled in the group health plan  Disclose such information to your health
in which you participate, and the like. We care providers and Wellmark’s health

ZY7 5AQ ZY8 5AR 86 Form Number: Wellmark IA Grp/GP_ 1012

 General Provisions

support service vendors, for purposes of implementing regulations (45 C.F.R. Parts
providing such services to you. 160-64). Any disclosure to and use by your
group sponsor of protected health
Wellmark will use and disclose information information will be subject to and consistent
according to the terms of our Privacy with the provisions identified under
Practices Notice, which is available upon Restrictions on Group Sponsor’s Use and
request or at www.wellmark.com. Disclosure of Protected Health Information
and Adequate Separation Between the
Value Added or Innovative Group Sponsor and the Group Health Plan,
Benefits later in this section.
Wellmark may, from time to time, make
Neither your group health plan, nor
available to you certain value added or
Wellmark, or any business associate
innovative benefits for a fee or for no fee.
servicing your group health plan will
Examples include discounts on
disclose protected health information to
alternative/preventive therapies, fitness,
your group sponsor unless the disclosures
exercise and diet assistance, and elective
are explained in the Notice of Privacy
procedures as well as resources to help you
Practices distributed to plan members.
make more informed health decisions.
Neither your group health plan, nor
Health Insurance Portability Wellmark, or any business associate
and Accountability Act of servicing your group health plan will
1996 disclose protected health information to
your group sponsor for the purpose of
Group Sponsor’s Certification of employment-related actions or decisions or
Compliance in connection with any other benefit or
Your group health plan, any business employee benefit plan of the group sponsor.
associate servicing your group health plan,
or Wellmark will not disclose protected Restrictions on Group Sponsor’s Use
health information to your group sponsor and Disclosure of Protected Health
unless your group sponsor certifies that Information
group health plan documents have been Your group sponsor will not use or further
modified to incorporate this provision and disclose protected health information,
agrees to abide by this provision. Your except as permitted or required by this
receipt of this summary plan description provision, or as required by law.
means that your group sponsor has Your group sponsor will ensure that any
modified your group health plan documents agent, including any subcontractor, to
to incorporate this provision, and has whom it provides protected health
provided certification of compliance to information, agrees to the restrictions and
Wellmark. conditions of this provision with respect to
protected health information and electronic
Purpose of Disclosure to Group protected health information.
Sponsor
Your group health plan, any business Your group sponsor will not use or disclose
associate servicing your group health plan, protected health information for
or Wellmark will disclose protected health employment-related actions or decisions or
information to your group sponsor only to in connection with any other benefit or
permit the group sponsor to perform plan employee benefit plan of the group sponsor.
administration of the group health plan Your group sponsor will report to the group
consistent with the requirements of the health plan, any use or disclosure of
Health Insurance Portability and protected health information that is
Accountability Act of 1996 and its

Form Number: Wellmark IA Grp/GP_ 1012 87 ZY7 5AQ ZY8 5AR

 General Provisions

inconsistent with the uses and disclosures integrity, and availability of electronic
stated in this provision promptly upon protected health information.
learning of such inconsistent use or
Your group sponsor will promptly report to
disclosure.
the group health plan any of the following
Your group sponsor will make protected incidents of which the group sponsor
health information available to plan becomes aware:
members in accordance with 45 Code of
 unauthorized access, use, disclosure,
Federal Regulations § 164.524.
modification, or destruction of the group
Your group sponsor will make protected health plan’s electronic protected health
health information available, and will on information, or
notice amend protected health information,  unauthorized interference with system
in accordance with 45 Code of Federal operations in group sponsor’s
Regulations § 164.526. information systems that contain or
Your group sponsor will track disclosures it provide access to group health plan’s
may make of protected health information electronic protected health information.
so that it can provide the information Adequate Separation Between the
required by your group health plan to Group Sponsor and the Group Health
account for disclosures in accordance with Plan
45 Code of Federal Regulations § 164.528. Certain individuals under the control of
Your group sponsor will make its internal your group sponsor may be given access to
practices, books, and records relating to its protected health information received from
use and disclosure of protected health the group health plan, a business associate
information available to your group health servicing the group health plan, or
plan, and to the U.S. Department of Health Wellmark. This class of employees will be
and Human Services to determine identified by the group sponsor to the group
compliance with 45 Code of Federal health plan and Wellmark from time to time
Regulations Parts 160-64. as required under 45 Code of Federal
Regulations §164.504. These individuals
When protected health information is no include all those who may receive protected
longer needed for the plan administrative health information relating to payment
functions for which the disclosure was under, health care operations of, or other
made, your group sponsor will, if feasible, matters pertaining to the group health plan
return or destroy all protected health in the ordinary course of business.
information, in whatever form or medium
received from the group health plan, These individuals will have access to
including all copies of any data or protected health information only to
compilations derived from and/or revealing perform the plan administration functions
member identity. If it is not feasible to that the group sponsor provides for the
return or destroy all of the protected health group health plan.
information, your group sponsor will limit Individuals granted access to protected
the use or disclosure of protected health health information will be subject to
information it cannot feasibly return or disciplinary action and sanctions, including
destroy to those purposes that make the loss of employment or termination of
return or destruction of the information affiliation with the group sponsor, for any
infeasible. use or disclosure of protected health
Your group sponsor will implement information in violation of or
administrative, physical, and technical noncompliance with this provision. The
safeguards that reasonably and group sponsor will promptly report such
appropriately protect the confidentiality, violation or noncompliance to the group
ZY7 5AQ ZY8 5AR 88 Form Number: Wellmark IA Grp/GP_ 1012
 General Provisions

health plan, and will cooperate with the which the services or supplies were
group health plan to correct the violation or provided.
noncompliance, to impose appropriate
disciplinary action or sanctions on each Medicaid Enrollment and
employee causing the violation or Payments to Medicaid
noncompliance, and to mitigate any
negative effect the violation or Assignment of Rights
noncompliance may have on the member, This group health plan will provide payment
the privacy of whose protected health of benefits for covered services to you, your
information may have been compromised beneficiary, or any other person who has
by the violation or noncompliance. been legally assigned the right to receive
such benefits pursuant to Title XIX of the
Your group sponsor will ensure that these Social Security Act (Medicaid).
provisions for adequate separation between
the group sponsor and the group health Enrollment Without Regard to
plan are supported by reasonable and Medicaid
appropriate security measures. Your receipt or eligibility for benefits under
Medicaid will not affect your enrollment as
Nonassignment a participant or beneficiary of this group
Benefits for covered services under this health plan, nor will it affect our
group health plan are for your personal determination of benefits.
benefit and cannot be transferred or
Acquisition by States of Rights of
assigned to anyone else without our
Third Parties
consent. You are prohibited from assigning
If payment has been made by Medicaid and
any claim or cause of action arising out of or
Wellmark has a legal obligation to provide
relating to this group health plan. Any
benefits for those services, Wellmark will
attempt to assign this group health plan or
make payment of those benefits in
rights to payment will be void.
accordance with any state law under which a
state acquires the right to such payments.
Governing Law
To the extent not superseded by the laws of Medicaid Reimbursement
the United States, the group health plan will When a PPO or participating provider
be construed in accordance with and submits a claim to a state Medicaid program
governed by the laws of the state of Iowa. for a covered service and Wellmark
Any action brought because of a claim under reimburses the state Medicaid program for
this plan will be litigated in the state or the service, Wellmark’s total payment for
federal courts located in the state of Iowa the service will be limited to the amount
and in no other. paid to the state Medicaid program. No
additional payments will be made to the
Legal Action provider or to you.
You shall not start any legal action against
us unless you have exhausted the applicable Subrogation
appeal process described in the Appeals
Right of Subrogation
section.
If you or your legal representative have a
You shall not bring any legal or equitable claim to recover money from a third party
action against us because of a claim under and this claim relates to an illness or injury
this group health plan, or because of the for which this group health plan provides
alleged breach of this plan, more than two benefits, we, on behalf of your plan sponsor,
years after the end of the calendar year in will be subrogated to you and your legal
representative’s rights to recover from the

Form Number: Wellmark IA Grp/GP_ 1012 89 ZY7 5AQ ZY8 5AR

 General Provisions

third party as a condition to your receipt of nothing to prejudice those rights. In

benefits. addition, at the time of making a claim for
benefits, you or your legal representative
Right of Reimbursement must inform us in writing if you were
If you are injured as a result of the act of a injured by a third party. You or your legal
third party and you or your legal representative must provide the following
representative files a claim under this group information, by registered mail, within
health plan, as a condition of receipt of seven (7) days of such injury to us as a
benefits, you or your legal representative condition to receipt of benefits:
must reimburse us for all benefits paid for
the injury from money received from the  The name, address, and telephone
third party or its insurer, to the extent of the number of the third party that in any
amount paid by this group health plan on way caused the injury, and of the
the claim. attorney representing the third party;
 The name, address and telephone
Once you receive benefits under this group
number of the third party’s insurer and
health plan arising from an illness or injury,
any insurer of you;
we will assume any legal rights you have to
collect compensation, damages, or any other  The name, address and telephone
payment related to the illness or injury from number of your attorney with respect to
any of the following: the third party’s act;
 Prior to the meeting, the date, time and
 The responsible person or that person’s location of any meeting between the
insurer. third party or his attorney and you, or
 Uninsured motorist coverage. your attorney;
 Underinsured motorist coverage.  All terms of any settlement offer made
 Other insurance coverage, including but by the third party or his insurer or your
not limited to homeowner’s, motor insurer;
vehicle, or medical payments insurance.  All information discovered by you or
your attorney concerning the insurance
You agree to recognize our rights under this
coverage of the third party;
group health plan to subrogation and
reimbursement. These rights provide us  The amount and location of any money
with a priority over any money paid by a that is recovered by you from the third
third party to you relative to the amount party or his insurer or your insurer, and
paid by this group health plan, including the date that the money was received;
priority over any claim for non-medical  Prior to settlement, all information
charges, or other costs and expenses. We related to any oral or written settlement
will assume all rights of recovery, to the agreement between you and the third
extent of payment made under this group party or his insurer or your insurer;
health plan, regardless of whether payment  All information regarding any legal
is made before or after settlement of a third action that has been brought on your
party claim, and regardless of whether you behalf against the third party or his
have received full or complete insurer; and
compensation for an illness or injury.  All other information requested by us.
Procedures for Subrogation and Send this information to:
Reimbursement
You or your legal representative must do Wellmark Blue Cross and Blue Shield of
whatever we request with respect to the Iowa
exercise of our subrogation and 1331 Grand Avenue, Station 5E151
reimbursement rights, and you agree to do Des Moines, IA 50309-2901

ZY7 5AQ ZY8 5AR 90 Form Number: Wellmark IA Grp/GP_ 1012

 General Provisions

You also agree to all of the following:

It is further agreed that in the event that you
 You will immediately let us know about fail to take the necessary legal action to
any potential claims or rights of recovery recover from the responsible party, we shall
related to the illness or injury. have the option to do so and may proceed in
 You will furnish any information and its name or your name against the
assistance that we determine we will responsible party and shall be entitled to the
need to enforce our rights under this recovery of the amount of benefits paid
group health plan. under this group health plan and shall be
 You will do nothing to prejudice our entitled to recover its expenses, including
rights and interests including, but not reasonable attorney fees and costs, incurred
limited to, signing any release or waiver for such recovery.
(or otherwise releasing) our rights, In the event we deem it necessary to
without obtaining our written institute legal action against you if you fail
permission. to repay us as required in this group health
 You will not compromise, settle, plan, you shall be liable for the amount of
surrender, or release any claim or right such payments made by us as well as all of
of recovery described above, without our costs of collection, including reasonable
obtaining our written permission. attorney fees and costs.
 If payment is received from the other You hereby authorize the deduction of any
party or parties, you must reimburse us excess benefit received or benefits that
to the extent of benefit payments made should not have been paid, from any present
under this group health plan. or future compensation payments.
 In the event you or your attorney receive
any funds in compensation for your You and your covered family member(s)
illness or injury, you or your attorney must notify us if you have the potential right
will hold those funds (up to and to receive payment from someone else. You
including the amount of benefits paid must cooperate with us to ensure that our
under this group health plan in rights to subrogation are protected.
connection with the illness or injury) in Our right of subrogation and
trust for the benefit of this group health reimbursement under this group health
plan as trustee(s) for us until the extent plan applies to all rights of recovery, and not
of our right to reimbursement or only to your right to compensation for
subrogation has been resolved. medical expenses. A settlement or judgment
 The amount of our subrogation interest structured in any manner not to include
shall be paid first from any funds medical expenses, or an action brought by
recovered on your behalf from any you or on your behalf which fails to state a
source, without regard to whether you claim for recovery of medical expenses, shall
have been made whole or fully not defeat our rights of subrogation and
compensated for your losses, and the reimbursement if there is any recovery on
“make whole” rule is specifically rejected your claim.
and inapplicable under this group health We reserve the right to offset any amounts
plan. owed to us against any future claim
 We will not be liable for payment of any payments.
share of attorneys’ fees or other
expenses incurred in obtaining any Workers’ Compensation
recovery, except as expressly agreed in If you have received benefits under this
writing, and the “common fund” rule is benefits plan for an injury or condition that
specifically rejected and inapplicable is the subject or basis of a workers’
under this group health plan.
Form Number: Wellmark IA Grp/GP_ 1012 91 ZY7 5AQ ZY8 5AR
 General Provisions

compensation claim (whether litigated or

not), we are entitled to reimbursement to
the extent of benefits paid under this plan
from your employer, your employer’s
workers’ compensation carrier, or you in the
event that your claim is accepted or
adjudged to be covered under workers’
compensation.
Furthermore, we are entitled to
reimbursement from you to the full extent
of benefits paid out of any proceeds you
receive from any workers’ compensation
claim, regardless of whether you have been
made whole or fully compensated for your
losses, regardless of whether the proceeds
represent a compromise or disputed
settlement, and regardless of any
characterization of the settlement proceeds
by the parties to the settlement. We will not
be liable for any attorney’s fees or other
expenses incurred in obtaining any proceeds
for any workers’ compensation claim.
We utilize industry standard methods to
identify claims that may be work-related.
This may result in initial payment of some
claims that are work-related. We reserve the
right to seek reimbursement of any such
claim or to waive reimbursement of any
claim, at our discretion.

Payment in Error
If for any reason we make payment in error,
we may recover the amount we paid.

Notice
If a specific address has not been provided
elsewhere in this summary plan description,
you may send any notice to Wellmark’s
home office:
Wellmark Blue Cross and Blue Shield of
Iowa
1331 Grand Avenue
Des Moines, IA 50309-2901
Any notice from Wellmark to you is
acceptable when sent to your address as it
appears on Wellmark’s records or the
address of the group through which you are
enrolled.

ZY7 5AQ ZY8 5AR 92 Form Number: Wellmark IA Grp/GP_ 1012

Glossary
The definitions in this section are terms that are used in various sections of this summary plan
description. A term that appears in only one section is defined in that section.
Accidental Injury. An injury,  Medicare (Part A or B of Title XVIII of
independent of disease or bodily infirmity the Social Security Act).
or any other cause, that happens by chance  Medicaid (Title XIX of the Social
and requires immediate medical attention. Security Act).
Admission. Formal acceptance as a  Medical care for members and certain
patient to a hospital or other covered health former members of the uniformed
care facility for a health condition. services, and for their dependents
(Chapter 55 of Title 10, United States
Amount Charged. The amount that a Code).
provider bills for a service or supply or the
 A medical care program of the Indian
retail price that a pharmacy charges for a
Health Service or of a tribal
prescription drug, whether or not it is
organization.
covered under this group health plan.
 A state health benefits risk pool.
Benefits. Medically necessary services or  Federal Employee Health Benefit Plan (a
supplies that qualify for payment under this health plan offered under Chapter 89 of
group health plan. Title 5, United States Code).
BlueCard Program. The Blue Cross and  A State Children’s Health Insurance
Blue Shield Association program that Program (S-CHIP).
permits members of any Blue Cross or Blue  A public health plan as defined in
Shield Plan to have access to the advantages federal regulations (including health
of PPO providers throughout the United coverage provided under a plan
States. established or maintained by a foreign
Compounded Drugs. Compounded country or political subdivision).
prescription drugs are produced by  A health benefits plan under Section
combining, mixing, or altering ingredients 5(e) of the Peace Corps Act.
by a pharmacist to create an alternate
strength or dosage form tailored to the Group. Those plan members who share a
specialized medical needs of an individual common relationship, such as employment
patient when an FDA-approved drug is or membership.
unavailable or a licensed health care Group Sponsor. The entity that sponsors
provider decides that an FDA-approved this group health plan.
drug is not appropriate for a patient’s
Illness or Injury. Any bodily disorder,
medical needs.
bodily injury, disease, or mental health
Creditable Coverage. Any of the condition, including pregnancy and
following categories of coverage, during complications of pregnancy.
which there was no break in coverage of
Inpatient. Services received, or a person
more than 63 days:
receiving services, while admitted to a
 Group health plan (including health care facility for at least an overnight
government and church plans). stay.
 Health insurance coverage (including Medical Appliance. A device or
group, individual, and short-term mechanism designed to support or restrain
limited duration coverage). part of the body (such as a splint, bandage

Form Number: Wellmark IA Grp/GL_ 1012 93 ZY7 5AQ ZY8 5AR

 Glossary

or brace); to measure functioning or Plan. The group health benefits program

physical condition of the body (such as offered to you as an eligible employee for
glucometers or devices to measure blood purposes of ERISA.
pressure); or to administer drugs (such as
Plan Administrator. The plan sponsor of
syringes).
this group health plan for purposes of the
Medically Urgent Situation. A situation Employee Retirement Income Security Act.
where a longer, non-urgent response time to
Plan Member. The person who signed for
a pre-service notification could seriously
this group health plan.
jeopardize the life or health of the benefits
plan member seeking services or, in the Plan Sponsor. The entity that sponsors
opinion of a physician with knowledge of this group health plan.
the member’s medical condition, would Plan Year. A date used for purposes of
subject the member to severe pain that determining compliance with federal
cannot be managed without the services in legislation.
question.
PPO Provider. A facility or practitioner
Medicare. The federal government health that participates with a Blue Cross or Blue
insurance program established under Title Shield preferred provider program.
XVIII of the Social Security Act for people
age 65 and older and for individuals of any Services or Supplies. Any services,
age entitled to monthly disability benefits supplies, treatments, devices, or drugs, as
under Social Security or the Railroad applicable in the context of this summary
Retirement Program. It is also for those plan description, that may be used to
with chronic renal disease who require diagnose or treat a medical condition.
hemodialysis or kidney transplant. Specialty Drugs. Drugs that are typically
Member. A person covered under this used for treating or managing chronic
group health plan. illnesses. These drugs often require special
handling (e.g., refrigeration) and
Nonparticipating Pharmacy. A administration. Some specialty drugs may
pharmacy that does not participate with the be taken orally, but others may require
network used by this prescription drug administration by injection, infusion, or
benefits plan. inhalation. Specialty drugs may not be
Nonparticipating Provider. A facility or available from a retail pharmacy.
practitioner that does not participate with a Spouse. A husband or wife as the result of
Blue Cross or Blue Shield Plan. a marriage that is legally recognized in your
Outpatient. Services received, or a person state of residence, including common law.
receiving services, in the outpatient We, Our, Us. Wellmark Blue Cross and
department of a hospital, an ambulatory Blue Shield of Iowa.
surgery center, or the home.
X-ray and Lab Services. Tests,
Participating Pharmacy. A pharmacy screenings, imagings, and evaluation
that participates with the network used by procedures identified in the American
this prescription drug benefits plan. Medical Association's Current Procedural
Participating Provider. A facility or Terminology (CPT) manual, Standard
practitioner that participates with a Blue Edition, under Radiology Guidelines and
Cross or Blue Shield Plan but not with a Pathology and Laboratory Guidelines.
preferred provider program. You, Your. The plan member and family
members eligible for coverage under this
group health plan.

ZY7 5AQ ZY8 5AR 94 Form Number: Wellmark IA Grp/GL_ 1012

Index
A changing plan options ...................................... 60
chemical dependency ................................... 11, 15
abuse of drugs ................................................... 29
chemical dependency treatment facility .......... 20
accidental injury................................................ 16
chemotherapy ............................................... 11, 15
acupressure ....................................................... 15
child support order ........................................... 56
acupuncture ................................................. 11, 15
children ................................................. 53, 56, 78
addiction ...................................................... 11, 15
chiropractic services .............................. 12, 22, 23
admissions .................................................. 41, 42
chiropractors................................................ 13, 23
adoption ............................................................ 53
claim filing ................................................... 73, 77
advanced registered nurse practitioners .... 13, 23
claim forms ....................................................... 73
allergy services ............................................. 11, 15
claim payment .................................................. 74
ambulance services ...................................... 11, 15
COBRA coverage............................................... 64
ambulatory facility ............................................ 20
coinsurance ................................................... 8, 47
ambulatory facility services .............................. 16
communication disorders................................. 22
amount charged ..........................................48, 50
community mental health center ..................... 20
anesthesia................................................ 11, 15, 16
complications.................................................... 33
appeals .........................................................41, 81
compounded drugs ........................................... 29
assignment of benefits ...................................... 89
concurrent review ............................................. 44
athletic trainers ................................................. 24
conditions of coverage ....................................... 31
audiologists ................................................. 13, 23
contraceptive devices........................................ 29
authority to terminate or amend ...................... 85
contraceptives ......................................... 11, 15, 16
authorized representative ................................. 85
contract ............................................................. 85
B contract amendment ........................................ 85
benefit coordination.......................................... 77 contract interpretation ............................... 85, 89
benefit year.................................................. 47, 49 convenience items ............................................ 33
benefit year deductible........................................ 7 convenience packaging ..................................... 29
benefit year maximum ........................................ 9 coordination of benefits.....................................77
benefits maximum .............................................. 9 coordination of care ........................................... 41
bereavement counseling ................................... 16 copayment.................................................. 7, 9, 10
biological products ............................................ 24 cosmetic drugs .................................................. 29
blood............................................................. 11, 15 cosmetic services ..........................................11, 16
BlueCard program ............................................ 37 cosmetic surgery .......................................... 13, 25
bone marrow transplants.................................. 26 counseling .....................................................11, 16
braces ..................................................... 19, 21, 25 coverage changes ................................... 59, 61, 85
brain injuries ..................................................... 45 coverage continuation ...................................... 64
brand name drugs ............................................. 50 coverage eligibility ............................................ 53
breast reconstruction ........................................ 25 coverage termination .............................61, 62, 63
creditable coverage ..................................... 55, 63
C
custodial care ..................................................... 19
care coordination .............................................. 41
cystic fibrosis .................................................... 45
case management .............................................. 45
changes of coverage .......................................... 61

95 ZY7 5AQ ZY8 5AR

 Index

D family deductible ................................................ 7

family member as provider .............................. 33
damaged drugs .................................................. 29
FDA-approved A-rated generic drug................ 50
deductible ........................................................ 7, 9
fertility services............................................ 12, 17
degenerative muscle disorders ......................... 45
filing claims.................................................. 73, 77
dental services .............................................. 11, 16
foot care (routine)............................................. 25
dependents ............................................ 53, 56, 78
foot doctors .................................................. 13, 23
DESI drugs ........................................................ 24
foreign countries ......................................... 29, 38
diabetes ........................................................ 12, 17
foster children ................................................... 53
diabetic education ........................................ 12, 17
fraud .................................................................. 63
dialysis.......................................................... 12, 17
full-time employees .......................................... 53
dietary products ................................................ 22
disabled dependents ......................................... 53 G
doctors......................................................... 13, 23 gamete intrafallopian transfer........................... 17
doctors of osteopathy .................................. 13, 23 generic drugs .................................................... 50
drug abuse .............................................. 11, 15, 29 genetic testing .............................................. 12, 18
drug exception process ..................................... 46 GIFT (gamete intrafallopian transfer) .............. 17
drug prior authorization ................................... 45 government programs .................................33, 77
drug quantities ............................................ 29, 50 gynecological examinations......................... 13, 25
drug rebates ...................................................... 52
H
drug refills ......................................................... 29
drug tiers ........................................................... 49 hairpieces ..................................................... 14, 27

drugs.................................................13, 24, 27, 52 hearing services ........................................... 12, 18

drugs that are not FDA-approved............... 24, 28 hemophilia ........................................................ 45

high risk pregnancy .......................................... 45
E home health services ............................. 12, 18, 45
education ...................................................... 11, 16 home infusion therapy...................................... 24
eligibility for coverage ....................................... 53 home office (Wellmark) .................................... 92
emergency room copayment............................... 7 home skilled nursing .........................................18
emergency services ...................................... 12, 17 home/durable medical equipment .............. 12, 19
employment physicals ...................................... 25 hospice respite care ........................................... 19
EOB (explanation of health care benefits) ....... 74 hospice services ........................................... 12, 19
ERISA ................................................................ 83 hospital services...........................................16, 62
exception process for noncovered drugs .......... 46 hospitals ...................................................... 12, 20
exclusion period ................................................ 55
I
exclusions .................................................... 31, 32
experimental or investigational drugs .............. 28 ID card .................................................. 35, 37, 38

experimental services ....................................... 32 illness .......................................................... 12, 20

explanation of health care benefits (EOB) ....... 74 immunizations .................................................. 25

eye services.................................................. 14, 27 impacted teeth ................................................... 16

eyeglasses .......................................................... 27 in vitro fertilization ............................................ 17

infertility drugs ................................................. 29
F infertility treatment ..................................... 12, 17
facilities ....................................................... 12, 20 information disclosure ..................................... 86
family and medical leave ...................................71 inhalation therapy ................................. 12, 19, 20
family counseling .............................................. 16 injectable drugs ................................................ 24
ZY7 5AQ ZY8 5AR 96
 Index

injury ........................................................... 12, 20 motor vehicles.............................................. 12, 22

inpatient facility admission ........................ 41, 42 muscle disorders ............................................... 45
inpatient services .............................................. 62 musculoskeletal treatment .......................... 12, 22
insulin diabetic supplies ................................... 21
N
investigational services ..................................... 32
network savings ................................................ 48
irrigation solutions and supplies ...................... 29
new employees .................................................. 55
K nicotine dependence ......................................... 24
kidney dialysis ....................................................17 nonassignment of benefits ............................... 89
nonmedical services .............................. 12, 22, 33
L
nonparticipating pharmacies ..................... 38, 50
L.P.N.................................................................. 18
nonparticipating providers............................... 48
laboratory services ...................................... 14, 27
notice ................................................................ 92
late enrollees .....................................................60
notification of change ........................................ 61
legal action ........................................................ 89
notification requirements .................................. 41
licensed independent social workers .......... 13, 23
nursing facilities ......................................... 20, 62
licensed practical nurses ................................... 18
nutritional products ......................................... 22
lifetime benefits maximum ........................... 9, 33
limitations of coverage ................. 9, 11, 31, 33, 50 O
lodging..........................................................13, 27 obesity treatment ......................................... 12, 22
lost or stolen items ............................................ 29 occupational therapists ............................... 13, 23
occupational therapy ............................. 12, 19, 23
M
office visit copayment ......................................... 8
mail order drug program .................................. 39
optometrists ................................................. 13, 23
mail order drugs................................................ 39
oral contraceptives ............................................ 16
mammograms ............................................. 13, 25
oral surgeons ............................................... 13, 23
marriage counseling.......................................... 16
organ transplants......................................... 13, 26
massage therapy................................................ 22
orthotics ....................................................... 12, 23
mastectomy ....................................................... 25
osteopathic doctors...................................... 13, 23
maternity services ........................................ 12, 21
other insurance ............................................33, 77
maximum allowable fee ..............................48, 50
out-of-area coverage ................................... 29, 36
medicaid enrollment ......................................... 89
out-of-pocket maximum ..................................... 8
medicaid reimbursement .................................. 89
other copayment ................................................. 8
medical doctors ........................................... 13, 23
oxygen .......................................................... 19, 21
medical equipment ................................ 12, 19, 29
medical supplies........................................... 12, 21 P
medical support order ...................................... 56 packaging .......................................................... 29
medically necessary .......................................... 31 pap smears ........................................................ 25
Medicare............................................................ 77 Pap smears ......................................................... 13
medicines .........................................13, 24, 27, 52 participating pharmacies............................ 38, 50
mental health services ................................. 12, 21 participating providers ............................... 35, 48
mental health treatment facility ....................... 20 payment arrangements...................................... 51
mental illness ............................................... 12, 21 payment in error ............................................... 92
military service .................................................. 33 payment obligations ....... 3, 31, 34, 38, 42, 49, 50
misrepresentation of material facts .................. 63 personal items .................................................. 33
morbid obesity treatment ........................... 12, 22 physical examinations ................................. 13, 25

97 ZY7 5AQ ZY8 5AR

 Index

physical therapists ...................................... 13, 23 rights of appeal ..................................................81

physical therapy ..................................... 13, 19, 23 routine services ............................................ 13, 25
physician assistants .................................... 13, 23
S
physicians.................................................... 13, 23
self-administered injections ............................. 24
plastic surgery .............................................. 11, 16
self-help ....................................................... 13, 26
podiatrists ................................................... 13, 23
service area ....................................................... 36
PPO providers ....................................... 35, 47, 48
service maximums ............................................. 11
practitioners ................................................ 13, 23
sexual identification disorders ......................... 22
precertification ............................................ 33, 41
skilled nursing services.......................... 12, 18, 20
preexisting conditions....................................... 55
sleep apnea .................................................. 13, 26
preferred provider organization (PPO) ............ 35
social workers .............................................. 13, 23
pregnancy .................................................... 20, 21
special enrollees................................................ 55
pregnancy (high risk) ........................................ 45
special enrollment events ................................. 60
prenatal services ............................................... 21
specialists .......................................................... 35
prescription drugs ..................... 13, 24, 27, 50, 52
specialty drugs ............................................ 24, 28
preventive care ............................................ 13, 25
specialty pharmacy program ............................ 38
prior approval ............................................. 34, 43
speech pathologists...................................... 13, 23
prior authorization...................................... 34, 45
speech therapy ............................................. 13, 26
prior creditable coverage .................................. 55
spinal cord injuries ........................................... 45
privacy ............................................................... 86
sports physicals................................................. 25
pronuclear stage transfer (PROST) ...................17
spouses .............................................................. 53
prosthetic devices................................... 13, 19, 25
status changes ................................................... 59
psychiatric medical institution for children
(PMIC) .......................................................... 20 stepchildren ...................................................... 53
psychiatric services ........................................... 21 sterilization .................................................. 17, 18
psychologists ............................................... 13, 23 subrogation ....................................................... 89
surgery ......................................................... 13, 26
Q surgical facility .................................................. 20
qualified medical child support order .............. 56 surgical facility services ..................................... 16
qualifying events ............................................... 59 surgical supplies .......................................... 12, 21
quantity limits ............................................. 29, 50
T
R temporomandibular joint disorder ............. 13, 26
R.N. .................................................. 13, 18, 21, 23 termination of coverage.........................61, 62, 63
radiation therapy ......................................... 11, 15 therapeutic devices ........................................... 29
rebates ............................................................... 52 third party liability............................................ 33
reconstructive surgery ................................ 13, 25 TMD (temporomandibular joint disorder) . 13, 26
refills.................................................................. 29 tooth removal..................................................... 16
registered nurses .............................. 13, 18, 21, 23 transplants ............................................. 13, 26, 45
reimbursement of benefits..........................90, 92 travel ............................................................ 13, 27
release of information ....................................... 86 travel physicals ................................................. 25
residential treatment .................................. 15, 22 tubal ligation ................................................ 17, 18
residential treatment facility ............................ 20
respiratory therapy ................................12, 19, 20
V
rights of action .................................................. 89 vaccines ............................................................. 24
vasectomy .................................................... 17, 18
ZY7 5AQ ZY8 5AR 98
 Index

vehicles ........................................................ 12, 22 Wellmark drug list ............................................ 52

vision services ............................................. 14, 27 wigs .............................................................. 14, 27
workers’ compensation................................ 33, 91
W
weight reduction ......................................... 12, 22 X
well-child care ............................................. 13, 25 x-rays ........................................................... 14, 27

99 ZY7 5AQ ZY8 5AR