Medical & Prescription Drugs HMO This plan uses Wellmark s Blue Advantage Network of providers.

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1 Medical & Prescription Drugs HMO This plan uses Wellmark s Blue Advantage Network of providers. Benefit Tier 1 - CRPHO Tier 2 - CRPHO Wellmark Blue Advantage Out of Pocket Maximum $500 EE $1,000 EE + SP $1,200 EE + CH $1,200 FAM $2,000 EE $3,000 EE + SP $4,000 EE + CH $4,000 FAM $1,000 EE $1,500 EE + SP $1,800 EE + CH $1,800 FAM $3,000 EE $4,000 EE + SP $5,000 EE + CH $5,000 FAM $1,500 EE $2,000 EE + SP $2,500 EE + CH $2,500 FAM $4,000 EE $5,500 EE + SP $6,500 EE + CH $6,500 FAM Co-Insurance 20% 30% 50% Preventative Care Services 0% ded waived 0% ded waived 0% ded waived Out-patient Lab & Radiology, Therapy $20 co-pay at MMC 30% after ded 50% after ded Urgent Care $20 copay 20% 40% Hospital 20% after ded 30% after ded 50% after ded Office Services $20 copay $40 copay $60 copay Emergency Room Facility Copay $150 copay visits 1-3 $250 copay visits 4-5 $450 copay visits 6 or more $150 copay visits 1-3 $250 copay visits 4-5 $450 copay visits 6 or more $150 copay visits 1-3 $250 copay visits 4-5 $450 copay visits 6 or more Physician 20% 20% 20% Employee Cost Rx Out-of-pocket Maximum Prescription Drugs Blue Rx Value Plus Tier 1 Drugs = $15 co-pay Tier 2 Drugs = $30 co-pay Tier 3 Drugs = $45 co-pay Specialty Drugs = $100 co-pay Non-preferred Specialty Drugs = 50% co-ins Employee $2,250 $5,000 $5,000 Family $5,000 Each participant in this plan must designate a primary care physician (PCP) in order for Wellmark to issue ID cards and process claims. Preventative Services (includes labs, immunizations, flu shots, etc.) must be performed by the PCP on file with Wellmark for the preventative services to be covered at 100%. PCP designations can be changed any time by calling Wellmark at Changes will go into effect the 1 st of the next month. Refer to the current list of Tier 1 and Tier 2 providers by going to: Portal/Teams/MPS-MPA/Human Resources. Tier 3 providers can be found by using the provider finder at and selecting the Blue Advantage network. If a covered member of a MercyCare medical plan requires a medical procedure which is not available at MMC, please contact HR prior to the date of service to review for the potential processing of facility charges at Tier 1. If you have a covered family member who is attending school or living outside the state of Iowa, call Wellmark for details about a Guest Membership for their acute services. Premiums Monthly Wellness Discount Rates 5% 15% Employee $ $97.65 $87.37 $ $ $ $ $ $ Family $ $ $ Part Time Employee $ $ $ $ $ $ $ $ $ Family $ $ $ A $50 monthly surcharge may be applied if you elect Employee+Spouse or Family. Refer to Health Plan Surcharge Form for more details. 5

2 High Health Plan with Health Savings Account This plan uses Wellmark s Alliance Select Network of providers. Plan Elements Tier 1 - CRPHO Tier 2 - CRPHO $2,600 EE $4,000 SP $5,200 CH $5,200 FAM $3,000 EE $4,800 SP $6,000 CH $6,000 FAM Tier 3 Wellmark Alliance Select Tier 4 Out of Network $4,000 EE $6,400 SP $8,000 CH $8,000 FAM Out of Pocket Max $2,600 EE $4,000 SP $5,200 CH $5,200 FAM $4,500 EE $7,200 SP $9,000 CH $9,000 FAM $5,500 EE $8,800 SP $11,000 CH $11,000 FAM Employer HSA $500/$750/$1,000 annualized Annual Funding *$500 for single, $750 for Employee+Child(ren) & Employee+Spouse, $1,000 for family Coinsurance 0% after ded 30% after ded 40% after ded 50% after ded Preventive Care 0% 0% 0% 0% Office Visit 0% after ded 30% after ded 40% after ded 50% after ded Chiropractic Visit n/a 30% after ded 40% after ded 50% after ded Inpatient/Outpatient Services 0% after ded 30% after ded 40% after ded 50% after ded Outpatient Lab, Radiology, PT/OT/ST 0% after ded 30% after ded 40% after ded 50% after ded Emergency Room Facility 20% after ded 20% after ded 20% after ded 20% after ded Practitioner 20% after ded 20% after ded 20% after ded 20% after ded Prescription Drug 0% after ded 30% after ded 40% after ded n/a Refer to the current list of Tier 1 and Tier 2 providers by going to: Portal/Teams/MPS- MPA/Human Resources. Tier 3 Alliance Select providers can be found by using the provider finder at and selecting the PPO Network. The Health Savings Account is administered through HealthEquity. Contact information can be found on page 3. Premiums Monthly Wellness Discount Rates 5% 15% Employee $60.00 $57.00 $51.00 $99.12 $94.16 $84.25 $ $ $ Family $ $ $ Part Time Employee $ $96.90 $86.70 $ $ $ $ $ $ Family $ $ $ HSA Contribution Limits Individual $3,400 Family $6,750 6

3 High Health Plan This plan uses Wellmark s Alliance Select Network of providers. Plan Elements Tier 1 - CRPHO Tier 2 - CRPHO $3,000 EE $4,800 SP $6,000 CH $6,000 FAM Tier 3 Wellmark Alliance Select $4,000 EE $6,400 SP $8,000 CH $8,000 FAM Tier 4 Out of Network $6,350 EE $12,700 SP $12,700 CH $12,700 FAM Out of Pocket Max $4,500 EE $7,200 SP $9,000 CH $9,000 FAM $5,500 EE $8,800 SP $11,000 CH $11,000 FAM $10,000 EE $20,000 SP $20,000 CH $20,000 FAM Coinsurance 30% after ded 40% after ded 50% after ded 60% after ded Preventive Care 0% 0% 0% 0% Office Visit 30% after ded 40% after ded 50% after ded 60% after ded Chiropractic Visit n/a 40% after ded 50% after ded 60% after ded Inpatient Services 30% after ded 40% after ded 50% after ded 60% after ded Outpatient Services 30% after ded 40% after ded 50% after ded 60% after ded Emergency Room Facility Physician MHCD 30% after deductible Prescription Drugs Blue Rx Value Plus Tier 1 Drugs Copay $15 Copay $15 Copay $15 Tier 2 Drugs Coins 30%/40% Coins 30%/40% Coins 30%/40% Tier 3 Drugs Specialty 50% Specialty 50% Specialty 50% n/a Refer to the current list of Tier 1 and Tier 2 providers by going to: Portal/Teams/MPS- MPA/Human Resources. Tier 3 Alliance Select providers can be found by using the provider finder at and selecting the PPO Network. Premiums Full-time Monthly Rates Employee $40.80 $67.40 $89.96 Family $95.90 Part-Time Monthly Rates Employee $52.64 $97.80 $ Family $

4 Dental Insurance Delta Dental administers the dental benefits for MercyCare Community Physicians. The summary of the plan is listed below; please refer to your certificate of coverage for a complete list of services. This plan allows you to seek treatment from any in-network dentist of your choice. Visit to locate an in-network provider or call (800) We use Delta Dental s Premier Network. Services Preventive Services Basic Services Major Services Annual Maximum 0% coinsurance; plan pays 100% for preventative services Applies to basic and major services only -- $50 per person / $150 Family Routine & Restorative 20% coinsurance Endodontics/Periodontics; gum and bone diseases, high cost restorations cast restorations, crowns, onlays, posts, and cores 50% coinsurance $1,000 Orthodontic 50% coverage to a lifetime maximum of $1,000 Monthly Rates Employee Only Spouse Child(ren) Family Full Time $12.45 $24.90 $32.37 $50.00 Part Time $14.60 $29.34 $37.64 $

5 Basic Vision Insurance Vision coverage will be administered through VSP. To find an in-network provider, visit We use VSP s Choice Basic Network. Benefit Description Copay Frequency WellVision Exam Focuses on your eyes and overall wellness $20 Prescription Glasses $25 See frames and lenses Frames $130 allowance; 20% off amount over allowance Every 24 months Lenses Single vision, lined bifocal and lined trifocal; Polycarbonate lenses for Lens Options Standard Progressive Premium Progressive Custom Progressive Average 20-25% off other lens options $55 $95 - $105 $150 - $175 Contacts (in lieu of ) $130 allowance; copay does not apply. Includes Lens Exam (fitting & evaluation) Up to $60 Diabetic Eyecare Plus Program Services related to Type 1 and Type 2 diabetes, ask your VSP doctor for details $20 As needed Glasses & Sun: 20% off additional and sun, including lens options from any VSP doctor within 12 months of your last WellVision exam. Extra Savings and Discounts Retinal Screening: No more than a $39 copay on routine retinal screening as an enhancement to your WellVision Exam. Laser Vision Correction: Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities. Monthly Rates Employee Only Spouse Child(ren) Family Full Time/Part Time $8.00 $16.00 $17.11 $25.93 NO ID CARD NECESSARY at your appointment, tell your eye care provider you have VSP. 9

6 Premier Vision Insurance Vision coverage will be administered through VSP. To find an in-network provider, visit We use VSP s Choice Premier Network. Benefit Description Copay Frequency WellVision Exam Focuses on your eyes and overall wellness $20 Prescription Glasses $25 See frames and lenses Frames $180 allowance; 20% off amount over allowance Every 12months Lenses Single vision, lined bifocal and lined trifocal; Polycarbonate lenses for Lens Options Progressive Anti-Reflective UV Average 20-25% off other lens options $50 $30 $0 Contacts (in lieu of ) $180 allowance; copay does not apply. Includes Lens Exam (fitting & evaluation) Up to $60 Diabetic Eyecare Plus Program Services related to Type 1 and Type 2 diabetes, ask your VSP doctor for details $20 As needed Glasses & Sun: 20% off additional and sun, including lens options from any VSP doctor within 12 months of your last WellVision exam. Extra Savings and Discounts Retinal Screening: No more than a $39 copay on routine retinal screening as an enhancement to your WellVision Exam. Laser Vision Correction: Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities. Monthly Rates Employee Only Spouse Child(ren) Family Full Time/Part Time $17.37 $34.72 $37.13 $56.28 NO ID CARD NECESSARY at your appointment, tell your eye care provider you have VSP. 10