The SHIP plan provisions chart below should be used as a general guide only. Please refer to the SHIP Coverage Manual (pdf) for further information. If the information provided in this summary chart differs from the coverage manual, the SHIP Wellmark Coverage Manual Document will govern.

Common Medical Plan Terms and Definitions

Deductible

Amount of money you pay out-of-pocket for care before plan begins to pay for benefits.

Copay

Flat dollar amount you'll pay for covered services at the time of service.

Coinsurance

Percentage you pay for covered services after you've reached your deductible.

OPM

Most you pay for covered services in plan year after paying deductibles, copays & coinsurance.

SHIP Classic Blue Plan Provisions
  In-Network Provider
Annual Deductible None. Please visit Annual Inpatient Deductible below.
Annual Inpatient Deductible1 $300 per person on plan for inpatient hospital stays only. 
Annual Out-of-Pocket Maximum (OPM)2 Medical OPM:
$1,700 for single
$3,400 for family
Prescription Drug OPM:
$1,000 for single
$2,000 for family
Coinsurance 10%
Copay The amount will depend on type of service. Please visit below for more information. 

1) Generally, you must pay all the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible.
2) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Premiums, balance-billed charges, and health care this plan doesn't cover do not count toward the out-of-pocket limit.

Office Visits, Services, and Hospital Stay Provisions
  In-Network Providers
Preventive Care3 Plan pays 100%
Primary Care and
Specialist Care Office Visits4
$10 copay
per provider per date of service
Mental Health Visits $10 copay
per provider per date of service
Chiropractic Care $10 copay
per provider per date of service
Allergy Treatments $15 copay
Speech, Occupational, Respiratory
and Physical Therapies
$15 copay
per provider per date of service
Routine Eye & Hearing Exams Not covered under plan
UI QuickCare $10 copay
per provider per date of service
Urgent Care $10 copay
per provider per date of service
Emergency Room Visits5 $50 copay
per visit for facility and physician(s) combined
Ambulance6 $15 copay
per provider per date of service
Inpatient Surgery7 10% coinsurance after $300 deductible
Outpatient Surgery

Facility Fee - 10% coinsurance
Physician/Surgeon fees -10% coinsurance

Imaging and Lab Work8 $15 copay
Durable Medical Equipment9 $15 copay
per provider per date of service
Dental Accident Care10 $15 copay;
treatment must be completed within 12 months of injury

3) Preventive care includes immunizations and well-child care (up to age 7), one routine physical and gynecological exam per calendar year unless medically necessary. Mammograms are unlimited. You may find a complete list of covered preventive services at the HealthCare.gov
4) You may see the specialist you choose without a referral.
5) The copay is waived if you are admitted as an inpatient of a facility immediately following emergency room services. For emergency medical conditions treated out-of-network, you may be balance billed.
6) For covered non-emergent situations, out-of-network ambulance services are NOT reimbursed at the in-network level. Benefits for non-participating ambulance providers are based on actual billed charges.
7) Pre-approval of inpatient admissions is required; Second surgical opinion is voluntary; The  inpatient day benefit limit of 180 days per calendar year includes skilled nursing days and home health visits. Transplants are limited to bone marrow/stem cell and kidney. Organ transplants only includes Cornea and kidney coverage only. will need prior approval before service.
8) Imaging (CT/PET scans, MRIs) and Labs are diagnostic tests such as x-rays and blood work.
9) Manual and electric breast pumps are covered at no charge. Hospital grade breast pumps are subject to copay.
10) Dental services are limited to accidental injuries treated within seven days of the injury; Limited surgical corrections to the jaw, mouth, and accessory sinus.

Other Covered Services and Excluded Services

Limitations may apply to these services. This is not a complete list.  

  • Applied Behavior Analysis therapy
  • Bariatric surgery
  • Chiropractic care
  • Medical Evacuation Benefit
    • SHIP will cover medical evacuation services in the event of illness or injury to students if necessary and adequate medical care cannot be provided at the location when the illness or injury occurs. Medical evacuation benefits cover expenses to the nearest appropriate medical facility. Pre-certification of medical evacuation services is required.
  • Most coverage provided outside the U.S.
  • Private-duty nursing - short term intermittent home skilled nursing (applies to home health care limit)
  • Repatriation Benefit
    • Repatriation benefits cover expenses incurred in returning the body to the person's place of residence in his or her home country including, but not limited to, the cost of embalming, the coffin, and transportation of the body.
  • Transgender Coverage
    • All of the health plans offered through the University of Iowa, which are administered by Wellmark Blue Cross and Blue Shield of Iowa, provides coverage of medically necessary covered services associated with gender transition-related treatment.

      Wellmark Blue Cross and Blue Shield of Iowa follows the national standards set forth by the World Professional Association for Transgender Health (WPATH) when deeming if a covered service is medically necessary.

      Covered services, when ordered by a health professional and deemed medically necessary associated with gender transition-related treatment, may include the following:
      • Hormone therapy;
      • Mental health services; and
      • Chest/breast and genital surgeries when ordered by a health professional.
        ​​​​​​​
    • Please contact Wellmark Blue Cross and Blue Shield of Iowa at 800-643-9724 for more information and to discuss the gender transition medical policy within the Interqual Prior Approval program to assure you have met all qualifications.

These are services your plan generally does NOT cover. Check your policy or plan document for more information and a list of any other excluded services.

  • Acupuncture
  • Cosmetic surgery
  • Custodial care - in home or facility
  • Dental care - adult
  • Dental check-up
  • Extended home skilled nursing
  • Eye exam
  • Glasses
  • Hearing aids
  • Infertility treatment
  • Long-term care
  • Routine eye care - adult
  • Routine foot care
  • Weight loss programs

ABOUT OUR SITE: 
The information presented on our website describes only the highlights of the plans and does not constitute official plan documents. Additional terms and conditions may apply. If there are any discrepancies between the information contained herein and the official plan documents, the plan documents will govern. For more detailed information you may contact Wellmark Blue Cross/Blue Shield at toll-free number 800-524-9242 (TTY: 888-781-4262), Monday through Friday from 7:30 a.m. to 5:00 p.m. (Central Time). For more efficient service, please have your member ID number handy - it can be found on the front of your card.