Medical Benefits

The chart below shows the four deductible options available to WELS VEBA health plan members.

PlanPlan 1Plan 2Plan 3*Plan 4
Individual Deductible$500$1000$2600$3500
Family Deductible$1000$2000$5200$7000
Individual Out-of-Pocket Max$1500$3000$5100$6000
Family Out-of-Pocket Max$3000$6000$10200$12000
Co-Insurance Percentage90% in-network
70% out-of-network
85% in-network
70% out-of-network
80% in-network
70% out-of-network
80% in-network
50% out-of-network

* Special note regarding Plan 3: Because Plan 3 is a high deductible health plan compliant for use with Health Savings Accounts (HSAs), IRS regulations require that prescription drug costs are subject to the medical deductible for individuals and families. This means that the total cost (less any applicable discounts) of a prescription drug must be paid at the time it is filled by the retail or mail pharmacy until the $2600 individual/$5200 family medical deductible is satisfied in a plan year. Once the Plan 3 member’s medical deductible is satisfied, the WELS VEBA plan pays 100% of the total covered prescription drug expenses for the remainder of that plan year.

Please note: The following is a summary of the available health benefits under WELS VEBA. Please refer to the applicable plan document on the Health Forms & Resources page for details regarding benefits and exclusions.

Benefits for Covered Medical Services

Plans 1, 2 and 4

Covered Services Payable at 100%

  • Ambulance Service (Air ambulance must be determined medically necessary)
  • Colonoscopies, if obtained by a Network provider (1 per Plan Year)
  • Home Health Care (50 nursing visits per Plan Year)
  • Mammograms, if obtained by a Network provider (1 per Plan Year)
  • Preventive Care Services as required by the Affordable Care Act of 2010, if obtained by a Network provider
  • Prostate Screenings, if obtained by a Network provider (1 per Plan Year)
  • Skilled Nursing Facility Care (30 days per Plan year)
  • Second Opinion exam and related services
  • Transplants provided by a BQCT facility (Transplant Services performed in a non-BQCT facility are subject to separate rules)

Covered Services Subject to Deductible and Coinsurance

  • Biofeedback for Illness (10 sessions per Plan Year)
  • Chemotherapy
  • Chiropractor Services (24 manipulations per Plan Year)
  • Durable Medical Equipment (rental or initial purchase; repair or replacement costs)
  • Home Health Care Services (other than nursing visits)
  • Hospital Benefits
  • Hospice Care
  • Maternity Benefits (48 hours Hospital care following normal delivery; 96 hours Hospital care following delivery by cesarean section)
  • Mental Health Benefits (Inpatient treatment requires precertification)
  • Newborn Infants
  • Nutritional Counseling
  • Oral Surgery
  • Orthoptic/Vision Therapy (1 initial exam and 4 therapy sessions per lifetime)
  • Other Covered Expenses
  • Outpatient Surgery
  • Physical Therapy, Occupational Therapy and Speech Therapy (combined limit of 40 visits per Plan Year)
  • Preventive Care Services obtained by a Non-Network provider or not required by the Affordable Care Act of 2010
  • Physician’s Services
  • Sleep Studies (2 per lifetime)
  • Substance Abuse Benefits (Inpatient treatment requires precertification)
  • Transplant Services provided by a POS, PPO, or Non-Network Facility

Covered Services Payable at 50% (not subject to Deductible)

  • Infertility Treatment (Maximum lifetime benefit: $5,000 per family)
Plan 3

Covered Services Payable at 100%

  • Colonoscopies, if obtained by a Network provider (1 per Plan Year)
  • Mammograms, if obtained by a Network provider (1 per Plan Year)
  • Preventive Care Services as required by the Affordable Care Act of 2010, if obtained by a Network provider
  • Prostate Screenings, if obtained by a Network provider (1 per Plan Year)

Covered Services Subject to Deductible and Coinsurance

  • Ambulance Service (Air ambulance must be determined medically necessary)
  • Biofeedback for Illness (10 sessions per Plan Year)
  • Chemotherapy
  • Chiropractor Services (24 manipulations per Plan Year)
  • Durable Medical Equipment (rental or initial purchase; repair or replacement costs)
  • Home Health Care (50 nursing visits per Plan Year)
  • Home Health Care Services (other than nursing visits)
  • Hospital Benefits
  • Hospice Care
  • Maternity Benefits (48 hours Hospital care following normal delivery; 96 hours Hospital care following delivery by cesarean section)
  • Mental Health Benefits (Inpatient treatment requires precertification)
  • Newborn Infants
  • Nutritional Counseling
  • Oral Surgery
  • Orthoptic/Vision Therapy (1 initial exam and 4 therapy sessions per lifetime)
  • Other Covered Expenses
  • Outpatient Surgery
  • Physical Therapy, Occupational Therapy and Speech Therapy (combined limit of 40 visits per Plan Year)
  • Preventive Care Services obtained by a Non-Network provider or not required by the Affordable Care Act of 2010
  • Physician’s Services
  • Second Opinion exam and related services
  • Skilled Nursing Facility Care (30 days per Plan year)
  • Sleep Studies (2 per lifetime)
  • Substance Abuse Benefits (Inpatient treatment requires precertification)
  • Transplant Services provided by a BQCT, POS, PPO, or Non-Network Facility

Covered Services Payable at 50% (subject to Deductible)

  • Infertility Treatment (Maximum lifetime benefit: $5,000 per family)

Benefits for Preventive Care Services

Benefits for Preventive Care services are the same for all WELS VEBA plan options. Benefits for Preventive Care services may vary based on the age and personal history of the member, and as determined appropriate by Anthem’s clinical coverage guidelines. Screenings and other services are generally covered as Preventive Care for adults and children with no current symptoms or prior history of a medical condition associated with that screening or service. Preventive Care is not subject to the Plan’s Coinsurance or Deductible as long as you use a network provider and the Preventive Care either (1) is billed separately from any other care received, or (2) is not billed separately but is the primary purpose of an office visit. Please be aware that, if a network provider bills Preventive Care separately from an office visit, the Plan’s Coinsurance or Deductible may apply to the portion of such office visit that does not constitute Preventive Care.

Members who have current symptoms or have been diagnosed with a medical condition are not considered to require Preventive Care for that condition but instead benefits will be considered under the Diagnostic Services benefit. If you would like to verify if a service is considered Preventive Care, please contact Anthem customer service at 1-877-512-7875.

Examples of some Preventive Care covered services are provided below.

Immunizations

  • Influenza virus vaccine
  • Hepatitis A vaccine
  • Hepatitis B vaccine
  • Hemophilus influenza b vaccine (Hib)
  • Diphtheria, Tetanus, Pertussis vaccine
  • Mumps virus vaccine
  • Measles virus vaccine
  • Rubella virus vaccine
  • Poliovirus vaccine
  • Shingles vaccine
  • Human Papillomavirus (HPV) Vaccine
  • Meningococcal vaccine
  • Varicella (chickenpox) vaccine

Screening Examinations

  • Routine screening mammograms
  • Routine chlamydia screening
  • Routine osteoporosis screening
  • Routine colorectal cancer examination and related laboratory tests
  • Routine prostate specific antigen testing

Contraceptives

The WELS VEBA health plan is exempt from the Affordable Care Act (ACA) mandate to cover certain contraceptive medications and services. Benefits for these ACA-mandated contraceptive medications and services are provided to WELS VEBA members under separate, stand-alone plans through Express Scripts and Anthem Blue Cross Blue Shield. Contraceptives are not covered under the WELS VEBA health plan, and WELS VEBA does not pay the cost of benefits or services provided through the separate Express Scripts and Anthem Blue Cross Blue Shield contraceptive plans. Click here for additional background material on WELS VEBA and ACA-mandated contraceptives.

A separate “contraceptive-only” identification card is provided under the Express Scripts contraceptive medication plan, and should be presented at the pharmacy to obtain medications covered under that plan. The identification number for the Express Scripts contraceptive-only coverage is different from your WELS VEBA identification number, and members should not present their WELS VEBA identification card to obtain contraceptive medications. Customer service for the Express Scripts contraceptive-only coverage is available at 1-866-237-0703.

Members would present their WELS VEBA identification card to their provider to obtain medical contraceptive services covered under the Anthem contraceptive plan. Claims for benefits will be processed and paid by Anthem under their separate plan for medical contraceptive services. Customer service for the Anthem medical contraceptive service coverage is available at 1-877-512-7875.