SHIP - UIGRADCare Comparison Effective January 1, 2017

Provision Comparison
PROVISIONS SHIP UIGRADCare
Co-insurance Percentage 10%; participating/non-participating providers 10%
Out-of-Pocket Maximums Single/Family $1,700 for single / $3,400 for family
Prescription Drugs:
$1,000 for single and $2,000 for family
$1,000 for single/$1,700 for family
Prescription Drugs:
$1,000 for single/$1,700 for family
Pre-approval of Inpatient Admissions Required Required
Second Surgical Opinion Voluntary Voluntary
Benefits Available from Non-member Providers Individual is responsible for charges above the maximum allowable fee Not available without approved referral
Domestic Partner Yes, same sex or opposite sex Yes, same sex or opposite sex
Dependent Child Age Limit End of calendar year in which the individual turns 26 or unlimited if full-time student End of calendar year in which the individual turns 26 or unlimited if full-time student
Preventive Care Comparison
PREVENTIVE CARE SERVICES SHIP UIGRADCare
Immunizations Covered; $0 co-payment Covered; $0 co-pay
Well-Child Care Covered; $0 co-pay Covered; $0 co-pay
Gynecological Pelvic Exams and Pap Smears Covered $0 co-pay (1 per calendar year unless medically necessary) Covered $0 co-pay (lab tests and materials 10% coinsurance)
Routine Preventive Exams Covered $0 co-pay (1 per calendar year unless medically necessary) Covered $0 co-pay (lab tests and materials 10% coinsurance)
Routine Eye & Hearing Exam Not covered $10 co-payment ($0 co-pay at UIHC)
Hospital Services Comparison
HOSPITAL SERVICES SHIP UIGRADCare
Room and Board Semi-private 10% co-insurance after $300 deductible 10% co-insurance after $125 daily deductible
Physicians Services 10% co-insurance 10% co-insurance
Inpatient / Outpatient Surgery & Supplies 10% co-insurance 10% co-insurance
Outpatient Services Comparison
OUTPATIENT SERVICES SHIP UIGRADCare
Ambulance $15 co-payment 10% co-insurance
Allergy Treatments $15 co-payment $10 co-payment
Imaging and Lab $15 co-payment $10 co-payment
Dental Accident Care $15 co-payment; treatment must be completed within 12 months of injury 10% co-insurance;
treatment must be completed within 12 months of injury
Durable Medical Equipment $15 co-payment 10% co-insurance
Speech, Occupational Respiratory, and Physical Therapy $15 co-payment 10% co-insurance
Office Visit
Chiropractor Visit
$10 co-payment $10 co-payment
Mental Health Office Visit $10 co-payment 0% co-insurance at UIHC or Wellmark Health Plan of Iowa Provider; 50% co-insurance out-of-network;
Out-of-network mental health and substance abuse limited to 50 visits per calendar year
Prescription Drugs Tier and what you pay per tier:
Tier 1: Generic drugs; 25%
Tier 2: Preferred name brand drugs; 30%
Tier 3: Non-preferred name brand drugs; 50%
$7 or 25%, whichever is greater
 
Home Health Care Maximum of 30 days/calendar year 10% co-insurance
Emergency Services $50 co-payment $50 co-payment followed by 10% co-insurance
Organ Transplants Prior approval; cornea, kidney coverage only Prior approval
Skilled Nursing Services Maximum of 30 visits per calendar year 10% co-insurance after $125 daily deductible
Not Covered Eyeglasses, Hearing Aid, Infertility Treatment, Travel Immunizations Eyeglasses, Hearing Aid, Infertility Treatment