Medical Benefit Plan FAQ
Where can I find information on what is covered under the plan?
The Master Plan Document/Summary Plan Description (MPD/SPD) is the document that contains all details about the City’s Medical Benefit Plan, including coverage, eligibility, exclusions, HIPAA, COBRA, appeal rights, and more. A hard copy is available from the City's Human Resources Department.
Who do I contact with questions about coverage or how my claim was processed?
The City uses third-party administrators for claims processing, utilization review, and customer service.
Medical Plan Administrator:
Professional Benefit Administrators (PBA)
Phone: (800) 435-5694
Website: www.pbaclaims.com
Prescription Drug Plan Administrator:
Serve You Rx
Phone: (800) 759-3203
Website: www.serve-you-rx.com
What is meant by “network,” and how do I know if my provider is in the network?
PBA partners with Anthem Blue Cross Blue Shield to provide access to Anthem’s nationwide and international network. Providers and facilities have contracted rates, which means lower costs for members.
Local in-network examples include:
- Emplify Health (Gundersen)
- Mayo Clinic Health Systems
- ViaroCare Primary Health
Members can search for additional in-network providers - including chiropractors and durable medical equipment suppliers through PBA's member portal which contains a link to Anthem's site to search their network.
What is the “Maximum Out of Pocket” of $10,600/$21,200 on the 2026 Traditional Plan?
Under the Affordable Care Act, health plans are required to have the Maximum Out of Pocket, often referred to as a MOOP. Under the law, if a covered person reaches this amount in out-of-pocket costs for in-network services, the plan must pay 100% of additional eligible expenses.
Under the City's Traditional Plan, it is extremely unlikely a member would reach the MOOP because out-of-pocket costs include only:
- Deductible
- Co-insurance (if applicable)
- Copays (physician, ER, chiropractic, prescription drugs)
How long can my child stay on the plan?
Dependents are eligible through the end of the month in which they turn age 26, regardless of marital status, school status, or financial support.
A dependent with a total and permanent disability (as defined in the Master Plan Document) may continue coverage beyond age 26.
Is a shingles shot covered?
Yes. The Shingrix shingles vaccination is covered at no cost when obtained from an in-network provider.
Are routine vision exams covered under the medical plan?
Yes. One routine vision exam per calendar year is covered.
All plans except ATU:
- In-network: $10 Copay/Deductible/10% Co-insurance
- Out-of-network: $10 Copay/In-network Deductible/30% Co-insurance
ATU plan:
- In-network: $10 Copay/Deductible
- Out-of-network: $10 Copay/In-network Deductible/20% Co-insurance
Are continuous glucose monitors and sensors for diabetes management covered under the plan?
Yes. A prescription and Prior Authorization are required. They may be obtained either way:
- Through the medical plan via an in-network medical equipment provider, or
- Through the pharmacy benefit at a retail pharmacy with a Tier 2 copayment
Is the “Cologuard” or “FIT” test covered?
Yes. These tests are covered at no cost when:
- Ordered by an in-network provider, and
- Coded as preventative screening
Note: If the test leads to a diagnostic colonoscopy, the colonoscopy is subject to normal cost-sharing.
Is a colonoscopy covered?
Yes. One routine in-network colonoscopy per year is covered at no cost.
Removal of polyps and the pathology charge as a result of the routine colonoscopy would also be covered without cost to the member.
If the lab/pathology claim has cost sharing applied for a routine colonoscopy, members should contact PBA to request reprocessing at 100%.
Can I go to the Neighborhood Family Clinic (NFC) for services?
Yes, depending on your plan:
- Traditional Plan: Services at NFC are no cost.
- High-Deductible Health Plan: $20 copay per visit, paid at the time of service.
- ATU Plan: NFC benefit is not available.
Note: NFC locations share space with Breidenbach Chiropractic, but those services are not part of NFC and follow normal medical plan benefits.
Reminder: Anthem’s LiveHealth Online (video doctoring) and Gundersen’s Express Care are also available at no cost to covered members.
Does the medical plan cover oral surgeries or dental-related services?
Yes. The plan covers 16 different oral surgeries plus the following services (cleanings, fillings, and most routine dental work are not covered under medical):
- Root canal therapy and related filling or crown within six months
- Major restorative services related to extraction and initial replacement of a natural erupted tooth
- Repair or replacement of a natural tooth damaged by blunt external force (not chewing), within six months
- Surgical exposure or removal of impacted un-erupted tooth
Note: Services under a, b, and c are limited to $3,000 per year.
Due to limited in-network providers for these services, out-of-network claims are currently paid at in-network levels by exception.
Coordination of benefits:
- The medical plan is primary over the City's voluntary dental plan.
- If a member has other dental insurance (not the City's), that plan is primary.
Is there a form to add a new family member to the plan (i.e. marriage, birth, adoption)?
Yes. Employees/Retirees must submit an enrollment form to HR within 31 days of the event to add a spouse or dependent(s). Contact HR for a benefits packet including the enrollment form.
See the MPD/SPD for complete details. If this summary conflicts with the MPD/SPD, the MPD/SPD will control. (Rev. 2/10/2025)