UISelect Plan Provisions

The plan provisions chart below should be used as a general guide only. Please refer to the UISelect Coverage Manual on our benefit resources page for further information. If the information provided in this summary chart differs fro m 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. 

UISelect Plan Provisions
  Level 1 Providers Level 2 Providers
Annual Deductible1 Single: $400
Family: $800
Single: $800
Family: $1,600
Annual Out-of-Pocket Maximum (OPM)2 Single: $2,000
Family: $3,400
Single: $3,000
Family: $6,000
Coinsurance 15% 25%
Copay Primary Care: $10
Specialist: $20
Primary Care: $35
Specialist: $50

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 own 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

Office Visits and Services Provisions
  Level 1 Providers Level 2 Providers
Preventive Care3 Plan pays 100%
Not subject to deductible
Plan pays 100%
Not subject to deductible
Office Visits4 You pay:
  • $10 copay for Primary Care Providers (PCP)
  • $20 copay for Specialist Care Providers
You pay:
  • $35 copay for Primary Care Providers (PCP)
  • $50 for Specialist Care Provider
Mental Health Visits You pay $10 copay You pay $10 copay
Routine Eye and Hearing Exams

You pay $35 copay
(UI Health Care providers)

You pay $50 copay
Doc on Demand5 Plan pays 100% Plan pays 100%
UI QuickCare You pay $5 copay N/A
Urgent Care You pay $10 copay You pay $35 copay
Emergency Room Visits6 You pay $100 copay followed by
10% coinsurance
You pay $100 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 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 defined as General and Family Practice, Internal Medicine, OB/GYN, Pediatricians, Nurse Practitioners and PAs. The primary care copay will apply towards chiropractic care, 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 is able to provide ASL (American Sign Language) and spoken language interpretation for medical visits.
6) The $100 copay will be waived if admitted to 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 applied to the remaining allowed amount.
7) Transplants must be done at UIHC or Blue Distinction Centers.
8) Hospice respite care is limited to 15 inpatient and 15 outpatient days per lifetime.

Other Covered Services and Excluded Services

  • Applied Behavior Analysis therapy-covered through age 18
  • Bariatric surgery
  • Chiropractic care
  • Hearing aids ($2,000 every 5 years)
  • 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)
  • Gender Transition Surgery - All of the health plans offered through the University of Iowa provide benefits for medically necessary covered services associated with gender transition when ordered by a health professional. Please contact Wellmark Blue Cross and Blue Shield at 800-643-9724 for more information and to discuss the gender transition medical policy.

  • 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