Description of Plans
PLAN | UISELECT | UICHOICE |
---|---|---|
DESCRIPTION AND HIGHLIGHTS |
UISelect is designed for employees who value high-quality coverage and want more of a say over their spending to meet financial needs. Members would pay lower monthly premiums than UIChoice, and if they use their coverage, they will pay a higher out-of-pocket cost for medical services. Highlights:
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UIChoice is a high-quality plan with extensive coverage inside and outside of Iowa. Premiums for UIChoice are higher than UISelect, and the out-of-pocket costs for medical services are lower. Highlights:
|
*Active Employee Premium Rates
UISelect | UIchoice | |
---|---|---|
Employee Only | $0 | $81 |
Employee+Spouse | $311 | $389 |
Employee+Child(ren) | $254 | $317 |
Employee+Family | $333 | $416 |
Double Spouse Family | $0 | $208 |
*The rates listed above are active employee rates. Please visit the Retiree Health Insurance Rates page to review retirees' rates.
Plan Provisions
UISELECT | UICHOICE | |||||
---|---|---|---|---|---|---|
PROVIDERS |
Level 1: All UI Health Care locations, including |
Level 2: Providers in the Blue Access network |
Level 3: Not covered, except in emergencies. (Dependent children attending college, long-term travelers, |
Level 1: All UI Health Care locations, including |
Level 2: Providers from the Blue Choice network |
Level 3: Participating providers from the BlueCard network. |
ANNUAL DEDUCTIBLE |
Level 1: Single: $500 Family: $1,000 |
Level 2: Single: $950 Family: $1,900 |
None. Deductible for inpatient care only for levels 1, 2, and 3. See Inpatient Care Deductible below. |
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ANNUAL INPATIENT CARE DEDUCTIBLE |
Level 1: See Deductible above. |
Level 2: See Deductible above. |
Level 1: $500 deductible, followed by 10% coinsurance |
Level 2: $750 deductible, followed by 10% coinsurance |
Level 3: $1,000 deductible, followed by 40% coinsurance |
|
COINSURANCE |
Level 1: 15% |
Level 2: 25% |
Level 1: 10% |
Level 2: 20%* |
Level 3: Varies based on location & service |
|
COPAY |
Level 1: Primary care Specialists: |
Level 2: Primary Care Specialists: |
Level 1: $15 copay |
Level 2: $30 copay |
Level 3: No copay. Subject to coinsurance depending on service. |
|
ANNUAL OUT-OF-POCKET MAXIMUM (OPM) |
Level 1: Single: $2,300 Family $4,000 |
Level 2: Single: $3,500 Family: $7,000 |
Level 1: Single: $2,000 Family: $4,000 Non-participating Providers: N/A |
Level 2: Single: $2,000 Family: $4,000 Non-participating providers: N/A |
Level 3: Single: $2,000 Family: $4,000 Non-participating providers: Single: $2,500 Family: $5,000 |
UISelect | UIChoice | |||||
---|---|---|---|---|---|---|
PREVENTIVE CARE |
Level 1: $0 copay Not subject to deductible |
Level 2: $0 copay Not subject to deductible |
Level 1: $0 copay |
Level 2: $0 copay |
Level 3: Participating Providers: Non-participating Providers: |
|
(Coinsurance waived for out-of-network immunizations & well-child care) |
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DOC ON DEMAND (Mental health and chemical dependency services NOT covered) |
Level 1: $0 copay |
Level 2: $0 copay |
Level 1: $0 copay |
Level 2: $0 copay |
Level 3: $0 copay |
|
UI QUICKCARE |
Level 1: $10 copay |
Level 2: N/A |
Level 1: $10 copay |
Level 2: N/A |
Level 3: N/A |
|
URGENT CARE |
Level 1: $15 copay |
Level 2: $40 copay |
Level 1: $15 copay |
Level 2: $30 copay |
Level 3: 50% coinsurance |
|
OFFICE VISITS |
Level 1: Primary Care Level 1: Specialists Care |
Level 2: Primary Care Level 2: Specialists Care |
Level 1: $15 copay |
Level 2: $30 copay |
Level 3: 50% coinsurance |
|
ROUTINE EYE & HEARING EXAMS |
Level 1: $40 copay |
Level 2: $55 copay |
Level 1: $15 copay |
Level 2: $30 copay |
Level 3: 50% coinsurance |
|
MENTAL HEALTH CARE VISITS |
Level 1: $15 copay |
Level 2: $15 copay |
Level 1: $0 copay |
Level 2: $0 copay |
Level 3: 50% coinsurance |
|
EMERGENCY ROOM VISITS |
Level 1: $150 copay followed by 10% coinsurance |
Level 2: $150 copay followed by 10% coinsurance |
Level 1: $125 copay followed by 10% coinsurance |
Level 2: $125 copay followed by 10% coinsurance |
Level 3: $125 copay followed by 10% coinsurance |
Prescriptions Drugs
Plan Formulary Name:
- Blue Rx Value Plus (UISelect)
- Blue Rx Complete (UIChoice)
To review each specific Wellmark formulary drug list, please visit Wellmark.com. Then, scroll down and choose the specific drug plan link you wish to access, and enter the name of the drug in the top left-hand corner to begin your search.
Note: Formulary Drug Lists are best viewed in Chrome.
Pharmacy Program Plan | UISelect Blue Rx Value Plus |
UIChoice Blue Rx Complete |
---|---|---|
Tier 1 Generic Drugs |
$0 copay | $0 copay |
Tier 2 |
30% coinsurance | 30% coinsurance |
Tier 3 Name-brand, non-formulary drugs |
50% coinsurance | 50% coinsurance |
Tier 4 Name-brand, non-formulary drugs |
N/A | 50% coinsurance |
Pharmacy Out-of-Pocket Maximum |
Employee: $2,000 Family: $4,000 |
Employee: $1,600 Family: $3,200 |
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, contact Wellmark Blue Cross/Blue Shield at the 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.