Preferred Provider Organization (PPO)

Under a PPO, you have coverage both in-network and out-of-network. You can see any doctor you choose, you don’t have to select a primary care physician (PCP), and you don’t need referrals to access specialists.

 

Under a PPO plan, you can:

  • Stay in-network and save money by using a network provider. Your out-of-pocket costs are lower because network providers typically offer their services at lower rates. In addition, you receive a higher level of benefits when you visit in-network providers.

  • Or, go out-of-network and use any doctor or hospital you’d like, but pay a greater share of the cost. You may be subject to reasonable and customary (R&C) limits.

Network:

Alliance Select

Group Number:

56851-0319 GreenState PPO

56851-0419 GreenState HDHP

56851-0309 Insurance PPO

56851-0409 Insurance HDHP

56851-0329 Trust PPO

56851-0429 Trust HDHP

Website:

https://www.wellmark.com/

Support:

1.800.524.9242

Claim Submission Address:

Wellmark BC/BS of IA

Station 39

636 Grand Avenue

Des Moines, IA 50309-2565

Find a Doctor

(Plan pre-fix: LDS)

BENEFITS

PPO

HDHP

Deductible

$1,500 Single

$3,000 Family

$3,000 Single

$6,000 Family

Coinsurance

80/20%

0%

Out of Pocket

Maximum

$3,000 Single

$6,000 Family

$3,000 Single

$6,000 Family

Office Visits

PCP: $20 copay

Specialist: $40 copay

Doctor on Demand: $40 Copay

PCP: Deductible applies

Specialist: Deductible applies

Doctor on Demand: $49 Copay

Preventative Services

Covered at 100%

Covered at 100%

Emergency Room

20% after deductible

Deductible applies

Urgent Care

$20 copay

Deductible applies

Inpatient Hospital

20% after deductible

Deductible applies

Outpatient Hospital

20% after deductible

Deductible applies

Prescription Drug

$100/$200 deductible

(waived for Tier 1)

Non-preferred Pharmacy Copay

(Walgreens and CVS)

$10 / $35 / $50 / $200

All Other Pharmacies Copay

$4 / $25 / $40 / $200

Deductible applies

Prescription Drug Out of Pocket Maximum

$3,000 Single

$6,000 Family

All prescription expenses apply to the Medical OPM.

There is no separate OPM.

In-Network Coverage

Most covered services are reimbursed at 80% after you meet the annual deductible.

Under the GreenState Traditional PPO, there is a $20 copayment for each office visit to a primary care physician, chiropractor, occupational therapist, physical therapist, speech pathologist, and mental health and chemical dependency treatment.  There is also a $40 copayment for each office visit to a specialist.

 

Out-of-Network Coverage

Most other covered services are reimbursed at 70% of the reasonable and customary costs, after you meet the annual deductible. 

 

Important Note:  You are responsible for all out of-network charges above the reasonable and customary limits, even if you have reached the out-of-pocket maximum.