SHIP - UIGRADCare Comparison

Provision Comparison
PROVISIONS SHIP UIGRADCare
Co-insurance Percentage 10% for Select inpatient hospital
20% for non-Select inpatient hospital
10%
Out-of-Pocket Maximums Single/Family $1700 PPO Providers
$2000 for Non-PPO providers
$1000 for Prescriptions Drugs
$1,200/$1,800
$1,200/$1,800 outpatient rx
Pre-existing Condition Waiting Period None None
Pre-approval of Inpatient Admissions Required Required
Second Surgical Opinion Voluntary Voluntary
Benefits Available from Non-member Providers Co-payment, deductibles, and co-insurances are higher plus individual is responsible for charges above the maximum allowable fee Not available without approved referral
Lifetime Maximum None None
Domestic Partner Yes, same sex or opposite sex Yes, same sex or opposite sex
Dependent Child Age Limit End of calendar year in which the individual turns 26 or unlimited if full-time student End of calendar year in which the individual turns 26 or unlimited if full-time student
Office Care Comparison
OFFICE CARE SHIP UIGRADCare
Office Calls $10 co-payment for Select provider
$30 co-payment for non-Select provider
$10 co-payment
Routine Physicals $0 co-pay (1 per calendar year) $0 co-pay (1 per calendar year)
Gynecological Pelvic Exams and Pap Smears Covered $0 co-pay (1 per calendar year unless medically-necessary) Covered $0 co-pay (1 per calendar year unless medically-necessary)
Imaging and Lab $10 co-payment at Physician’s Office;
$30 co-payment at Outpatient Facility
10% co-insurance
Well-Child Care Covered; $0 co-pay Covered; $0 co-pay
Routine Eye & Hearing Exam Not covered $10 co-payment ($0 co-pay at UIHC)
Hospital Services Comparison
HOSPITAL
SERVICES
SHIP UIGRADCare
Room and Board Semi-private 10% co-insurance after $300 deductible for Select hospital; 20% co-insurance after $600 deductible for non-Select hospital 10% co-insurance after $125 daily deductible
Physicians Services Included in hospital deductible and co-insurance 10% co-insurance
Inpatient Surgery 10% co-insurance after $300 deductible for Select hospital; 20% co-insurance after $600 deductible for non-Select hospital; semi-private room 10% co-insurance
Outpatient Surgery $50 co-payment for Select hospital
$150 co-payment for non-Select hospital
10% co-insurance
Inpatient Supplies, Drugs, Tests, ICU, Operating Room, and Specialized Care 10% co-insurance after $300 deductible for Select hospital; 20% co-insurance after $600 deductible for non-Select hospital 10% co-insurance
Outpatient Services Comparison
OUTPATIENT SERVICES SHIP UIGRADCare
Ambulance $10 co-payment for Select providers
$30 co-payment for non-Select
10% co-insurance
Allergy Treatments $10 co-payment for Select physician
$30 co-payment for non-Select
$10 co-payment
Chiropractor $10 co-payment for Select providers
$30 co-payment for non-Select
$10 co-payment
Dental Accident Care $10 co-payment for Select
$30 co-payment for non-Select;
treatment must be completed within 12 months of injury
10% co-insurance;
treatment must be completed within 12 months of injury
Durable Medical Equipment $10 co-payment for Select providers
$30 co-payment for non-Select providers
10% co-insurance
Speech, Occupational Respiratory, and Physical Therapy $10 co-payment for Select providers
$30 co-payment for non-Select providers
10% co-insurance
Prescription Drugs Tier and what you pay per tier:
Tier 1: Generic drugs-25%
Tier 2: Name brand formulary
drugs-30%
Tier 3: Name brand non-formulary drugs-50%
$7 or 25%, whichever is greater
$1,200 OPM for single contract
 
Generic Contraceptive Drugs Covered; $0 co-pay Covered, $0 co-pay
Immunizations Covered; $0 co-pay Covered; $0 co-pay
Home Health Care Maximum of 30 days/calendar year 10% co-insurance
Emergency Services $50 co-payment $50 co-payment followed by 10% co-insurance
Organ Transplants Prior approval; cornea, kidney coverage only Prior approval
Skilled Nursing Services Maximum of 30 visits per calendar year 10% co-insurance after $125 daily deductible
Hospice Care Covered 10% co-insurance
Not Covered Eyeglasses, Hearing Aid, Infertility Treatment Eyeglasses, Hearing Aid, Infertility Treatment