The plan provisions chart comparison should be used as a general guide only. Please refer to the SHIP and/or UIGRADCare Coverage Manuals for further information. If the information provided in this summary chart differs from the coverage manual, the SHIP and/or UIGRADCare 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. 

Coinsurance

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

Copay

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

OPM

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

Plan Provisions

SHIP vs. UIGRADCare Plan Provisions
  SHIP UIGRADCare
PROVIDERS

In-network providers:
Alliance Select PPO

Must use Student Health or UIHC Providers.
The plan will not cover providers outside the UI Health Care network. 
DEDUCTIBLE

$500 single/year

$1,000 family/year

 n/a
COINSURANCE

20% in-network

40% out-of-network

 10% in-network
COPAY Primary care office visit:
$25 copay for in-network, 40% out-of-network
Specialist office visit:
$50 copay for in-network, 40% out-of-network

Emergency room: $150 copay

Office visits and other services: 
$10 copay

Emergency room:
$50 copay
OUT-OF-POCKET MAXIMUM (OPM)
 

Health:
$5,000 single / $10,000 family

UIHC Providers:
$1,000 single / $1,700 family
Prescription Drugs:
$1,000 single / $1,700 family

The Provider and Drug OPM's accumulate separately.
Premiums, balance-billed charges, and health care
from providers that UIGRADCare does not cover will
not count toward your OPM. 
PRE-APPROVAL of INPATIENT ADMISSIONS Pre-approval is REQUIRED for both SHIP and UIGRADCare for inpatient admissions. 
DEPENDENT CHILD AGE LIMIT Effective Jan. 1, 2021, the dependent child is covered up to age 26.
SHIP or UIGRADCare will not allow coverage for a full-time student
dependent child(ren) after age 26.

 Preventive Care Services

SHIP and UIGRADCare Preventive Care Comparison
  SHIP
in-network		 SHIP
out-of-network		 UIGRADCARE
IMMUNIZATIONS $0 copay 40% coinsurance UI Health Care: $0
Out-of-Network: Not covered
WELL-CHILD CARE
(TO AGE 7)		 $0 copay 40% coinsurance UI Health Care: $0
Out-of-Network: Not covered
GYNECOLOGICAL PELVIC
EXAMS AND PAP SMEARS		 $0 copay
(one per calendar year unless
medically necessary)		 40% coinsurance
(one per calendar year unless
medically necessary)

UI Health Care: $0
Lab Tests/Materials: 10% coinsurance
(unlimited Gynecological visits)

Out-of-Network: Not covered
ROUTINE PREVENTIVE EXAMS
 		 $0 copay
(one per calendar year, unless
medically necessary. Mammograms
are unlimited.)		 40% coinsurance
(one per calendar year, unless
medically necessary. Mammograms
are unlimited.)		 UI Health Care: $0
(unlimited preventive exams and mammograms)

Out-of-Network: Not covered
ROUTINE EYE AND HEARING EXAMS Not covered Not covered UI Health Care: $0
Other: $10 copay

Hospital Services

Hospital Services
  SHIP
in-network		 SHIP
out-of-network		 UIGRADCare
ROOM & BOARD
(SEMI-PRIVATE)		 $500 deductible,
followed by 20% coinsurance		 $500 deductible,
followed by 20% coinsurance		 $125 daily copayment,
followed by 10% coinsurance
PHYSICIANS SERVICES 20% coinsurance 40% coinsurance 10% coinsurance
INPATIENT/OUTPATIENT
SURGERY & SUPPLIES		 20% coinsurance 40% coinsurance 10% coinsurance

Outpatient Services

Outpatient Services
  SHIP
in-network		 SHIP
Out-of-network		 UIGRADCare
  The deductible must be met before the insurance covers the cost. Coinsurance
applies after meeting the deductible.		 N/A
AMBULANCE 20% coinsurance 40% coinsurance 10% coinsurance
IMAGING AND LAB 20% coinsurance 40% coinsurance 10% coinsurance
DURABLE MEDICAL EQUIPMENT 20% coinsurance 40% coinsurance 10% coinsurance
SPEECH, OCCUPATIONAL, AND PHYSICAL THERAPY $25 copay 
$50 copay for specialist		 40% coinsurance 10% coinsurance
OFFICE VISIT Primary Care Provider: $25 copay
Specialist Provider: $50 copay		 40% coinsurance $10 copay
MENTAL HEALTH OFFICE VISIT $0 copay 40% coinsurance 0% coinsurance at UIHC or Wellmark Health Plan of Iowa Provider;
50% coinsurance out-of-network;
Out-of-network mental health and substance abuse limited to 50 visits per calendar year
PRESCRIPTION DRUGS

Blue Rx Value Plus Formulary
Tier 1 drugs: 25% coinsurance
Tier 2 drugs: 30% coinsurance
Tier 3 drugs: 50% coinsurance

Blue Rx Complete Formulary

$7 or 25% coinsurance, whichever is greater
EMERGENCY SERVICES $150 copay $150 copay $50 copay followed by 10% coinsurance
NOT COVERED Eyeglasses, hearing aid, infertility treatment, travel vaccinations and immunizations Eyeglasses, hearing aid, infertility treatment


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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.