Description of Plans and Rates
PLAN | UISELECT | UICHOICE |
---|---|---|
DESCRIPTION AND HIGHLIGHTS |
UISelect is designed for employees who value Highlights:
|
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:
|
RATES | UISelect Monthly Premiums | UIChoice Monthly Premiums |
Employee Only | $0 | $72 |
Employee+Spouse | $285 | $342 |
Employee+Child(ren) | $233 | $279 |
Employee+Family | $306 | $367 |
Double Spouse Family | $0 | $183 |
Plan Provisions
PLAN | 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: $400 Family: $800 |
Level 2: Single: $800 Family: $1,600 |
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: $400 deductible, followed by 10% coinsurance |
Level 2: $600 deductible, followed by 10% coinsurance |
Level 3: $800 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: $10 copay |
Level 2: $25 copay |
Level 3: No copay. Subject to coinsurance depending on service. |
|
ANNUAL OUT-OF-POCKET MAXIMUM (OPM) |
Level 1: Single: $2,000 Family $3,400 |
Level 2: Single: $3,000 Family: $6,000 |
Level 1: Single: $1,700 Family: $3,400 Non-participating Providers: N/A |
Level 2: Single: $1,700 Family: $3,400 Non-participating providers: N/A |
Level 3: Single: $1,700 Family: $3,400 Non-participating providers: Single: $2,000 Family: $4,000 |
|
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 |
Level 1: $0 copay |
Level 2: $0 copay |
Level 1: $0 copay |
Level 2: $0 copay |
Level 3: $0 copay |
|
UI QUICKCARE |
Level 1: $5 copay |
Level 2: N/A |
Level 1: $5 copay |
Level 2: N/A |
Level 3: N/A |
|
URGENT CARE |
Level 1: $10 copay |
Level 2: $35 copay |
Level 1: $10 copay |
Level 2: $25 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: $10 copay |
Level 2: $25 copay |
Level 3: 50% coinsurance |
|
MENTAL HEALTH CARE VISITS |
Level 1: $10 copay |
Level 2: $10 copay |
Level 1: $0 copay |
Level 2: $0 copay |
Level 3: 50% coinsurance |
|
EMERGENCY ROOM VISITS |
Level 1: $100 copay followed by 10% coinsurance |
Level 2: $100 copay followed by 10% coinsurance |
Level 1: $100 copay followed by 10% coinsurance |
Level 2: $100 copay followed by 10% coinsurance |
Level 3: $100 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. Scroll down and choose the specific drug plan link you wish to access and enter the name of the drug in the top lefthand 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: $1,100 Family: $2,200 |
Employee: $1,100 Family: $2,200 |
Need help in selecting the best plan for you?
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.