Plan provisions
The plan provisions chart below should be used as a general guide only. Please refer to the UISelect Coverage Manual (pdf) for further information. If the information in this summary chart differs from the coverage manual, the UISelect 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.
| Level 1 | Level 2 | |
|---|---|---|
| Annual Deductible1 | Single: $500 Family: $1,000 | Single: $950 Family: $1,900 |
| Annual out-of-pocket MEDICAL maximum (OPM)2 | Single: $2,300 Family: $4,000 | Single: $3,500 Family: $7,000 |
| Annual out-of-pocket PRESCRIPTION maximum (OPM) | Single: $2,450 | |
| Coinsurance | 15% | 25% |
| Copay | Primary Care: $15 Specialist: $25 | Primary Care: $40 Specialist: $55 |
1) Generally, you must pay all the costs from providers up to the deductible amount before the plan begins to pay. If you have other family members on the plan, each family member must meet their individual (single) deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
2) Annual maximum limit for both individuals and families. When the amount paid in coinsurance and deductibles equals the applicable OPM, the plan pays 100% of covered services within the calendar year. If a plan member meets the individual OPM, the additional plan member(s) continue to pay coinsurance and deductibles until the larger OPM for their plan is met. The OPM can also be met when no individual plan member meets their individual OPM, but the combination of the out-of-pocket expenses for all the plan members meets the appropriate OPM for the plan.
Office visits, services, and hospital stays
| Level 1 | Level 2 | |
|---|---|---|
| Preventive Care3 | Plan pays 100% Not subject to deductible | Plan pays 100% Not subject to deductible |
| Office Visits4 | You pay: $15 copay for Primary Care Providers (PCP) $25 copay for Specialist Care Providers | You pay: $40 copay for Primary Care Providers (PCP) $55 copay for Specialist Care Provider |
| Mental Health Visits | $0 copay | $0 copay |
| Routine Eye and Hearing Exams | $40 copay (UI Health Care providers) | $55 copay |
| Doc on Demand5 | Plan pays 100% | Plan pays 100% |
| UI QuickCare | $10 copay | N/A |
| Urgent Care | $15 copay | $40 copay |
| Emergency Room Visits6 | You pay $150 copay followed by 10% coinsurance | You pay $150 copay followed by 10% coinsurance |
| Hospital Stay, Facility7 | You pay 15% coinsurance | You pay 25% coinsurance |
| Hospital Stay, Physician/surgeon fees | You pay 15% coinsurance | You pay 25% coinsurance |
| Home Health Care | You pay 15% coinsurance | You pay 25% coinsurance |
| Skilled Nursing Care | You pay 15% coinsurance | You pay 25% coinsurance |
| Hospice Services8 | You pay 15% coinsurance | You pay 25% coinsurance |
| Durable Medical Equipment | You pay 15% coinsurance | You pay 25% coinsurance |
| Imaging & Lab Services | You pay 15% coinsurance | You pay 25% coinsurance |
3) One preventive exam, one gynecological exam with a pap smear, and one mammogram per calendar year. Well-child care is covered to age 7. Preventive care must be provided by a primary care provider (PCP).
4) Office visits are split among primary care providers and specialist providers. Primary care providers (PCP) are general and Family Practice, Internal Medicine, OB/GYN, Pediatricians, Nurse Practitioners, and PAs. The primary care copay will apply to chiropractic care and physical, speech & occupational therapies.
5) Doctor on Demand is free care anywhere 24/7 for covered employees and their dependents. With Doc on Demand, you can have video visits with board-certified physicians and get treatment and prescriptions (member cost-share applies) for a cold, flu, allergies, and more. Doctor on Demand can provide ASL (American Sign Language) and spoken language interpretation for medical visits.
6) The $150 copay will be waived if admitted to the hospital, and depending on where you are being seen, Level 1 or 2 provider, the applicable level's deductible and coinsurance will apply. The coinsurance follows the copay because the copay will be first subtracted from the allowed amount for the hospital facility charge, and the 10% coinsurance will be applied to the remaining allowed amount.
7) Transplants must be done at UI Health Care or Blue Distinction Centers.
8) Hospice respite care is limited to 15 inpatient and 15 outpatient days per lifetime.
Other Covered Services, Excluded Services, and FAQ's
Other services covered
- Applied Behavior Analysis therapy-covered through age 18
- Bariatric surgery
- Chiropractic care
- Hearing aids ($1,500 every 36 months) - Hearing Aids and hearing aid services must be made/received in-network (Level 1 or Level 2). They would be subject to the deductible first (if the member has not already met it for the calendar year) and then coinsurance.
- Infertility treatment ($15,000 Life Time Maximum)
- Private-duty nursing - short-term intermittent home skilled nursing
- Routine eye care - Adult (one vision exam per calendar year)
Guest membership criteria
The UISelect member must call Wellmark Blue Cross Blue Shield of Iowa customer service to obtain the guest membership. The customer service number is listed on the back of their health insurance card or they may find contact information on Wellmark's website.
Criteria for guest memberships:
- Dependent children attending college: Guest membership is available to a student/dependent of the policyholder who is out of the area for 90 or more consecutive days.
- Long-term travelers: Guest membership is available to a policyholder, spouse, or other dependents who are away from the area in the U.S. for at least 90 consecutive days.* The member will be asked for their approximate date of return.
- Example: Used for long-term work assignments or a retiree with dual residence.
- The permanent address must be an Iowa address.
- Families living apart: Guest membership is available to a spouse or other dependents of the policyholder who do not reside in the area for 90 or more consecutive days. The policyholder is NOT eligible for this type of guest membership.
- Example: Typically used when divorced or separated family members permanently reside outside of the area
- Example: Typically used when divorced or separated family members permanently reside outside of the area
- COBRA: COBRA guest membership is available to a policyholder, spouse, or other dependents who obtain residence in another state. COBRA guest membership will remain in effect as long as COBRA is in effect or until the member returns to reside in Iowa, whichever comes first.
Medical services received by those on a Guest Membership will have coverage under Level 2 if a participating Blue Cross Blue Shield provider provides services.
*The guest membership program is unavailable for international services when traveling outside the country. If you are an employee traveling internationally for university business purposes, then the CISI insurance will apply.
Excluded services
- Acupuncture
- Cosmetic surgery
- Custodial care - in home or facility
- Dental care - Adult
- Dental check-up
- Extended home skilled nursing
- Glasses
- Long-term care
- Non-emergency care when traveling outside the U.S.
- Routine foot care
- Some pharmacy drugs are not covered
- Weight loss programs
How is physical therapy covered?
Office-based physical therapy will be covered with an office copay amount being owed. Facility-based physical therapy when received in a hospital will be covered as ‘inpatient or outpatient’ with coinsurance being owed.
*NOTE: For UISelect, facility-based physical therapy covered as ‘inpatient or outpatient’ will be subject to the deductible.
ABOUT OUR SITE:
Our website's information 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, contact Wellmark Blue Cross/Blue Shield at 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.