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 OPM for PPO Providers
$2000 for Non-PPO providers
$1000 for prescriptions
$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
Prior Approval for Outpatient Surgery None Physician discretion
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 referrals
Dependent Child Age Limit End of calendar year after turning 26 or unlimited if full-time student End of calendar year after turning 26 or unlimited if full-time student
Lifetime Maximum None None
Office Care Comparison
OFFICE CARE SHIP UIGRADCare
Office Calls $10 co-payment for Select providers
$30 co-payment for non-Select
$10 co-payment
Routine Physicals $0 co-pay (1 per calendar year);
$10% co-insurance for lab and imaging
$0 co-pay (1 per calendar year); $10% co-insurance for lab and imaging
Gynecological pelvic examinations and Pap Smears Covered (1 per calendar year unless medically-necessary) Covered (1 per calendar year unless medically-necessary)
Imaging and Lab Diagnostic only;
$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 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 after $125 daily deductible; semi-private room
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
Inpatient Supplies, Drugs 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 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
10% co-insurance
Speech, Occupational Respiratory, and Physical Therapy $10 co-payment for Select providers
$30 co-payment for non-Select
10% co-insurance
Prescription Drugs and
Oral Contraceptives
3 tier plan:
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
$1,800 for all other contracts
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
Outpatient Surgery $50 co-payment for Select hospital
$150 co-payment for non-Select hospital
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