Wellmark Blue Cross / Blue Shield Plan Documents:
- 2021 UIGRADCare Summary of Benefits and Coverage (pdf)
- 2020 UIGRADCare Coverage Manual (pdf)
- UIGRADCare Coverage Manual (pdf)
- UIGRADCare Summary of Benefits and Coverage (pdf)
UIGRADCare Plan Provisions
|Out-of-Pocket Maximum (OPM)||Medical OPM:
$1,000 for Single
$1,700 for Family
|Prescription Drug OPM:
$1,000 for Single
$1,700 for Family
|Benefits Available from Out of Network Providers||Not available without approved referral|
Preventive Care Services
|Well-Child Care (to age 7)||$0 Copay|
|Gynecological Pelvic Exams and Pap Smears||$0 Copay (lab tests and materials 10% coinsurance)|
|Routine Preventive Exams||$0 Copay (lab tests and materials 10% coinsurance)|
|Routine Eye & Hearing Exams||$10 Copay ($0 Copay at UIHC)|
|Room and Board, Semi-Private||10% Coinsurance after $125 daily deductible|
|Physicians Services||10% Coinsurance|
|Inpatient / Outpatient Surgery & Supplies||10% Coinsurance|
|Allergy Treatments||$10 Copay|
|Imaging and Lab||10% Coinsurance|
|Dental Accident Care||10% Coinsurance; treatment must be completed within 12 months of injury|
|Durable Medical Equipment||10% Coinsurance|
|Speech, Occupational, Respiratory, and Physical Therapy||10% Coinsurance|
|Mental Health Office Visit||0% Coinsurance at UIHC or Wellmark Health Plan of Iowa Provider;
50% Coinsurance out-of-network;
Out-of-network mental health and substance abuse limited to 50 visits per calendar year.
|Prescription Drugs||$7 or 25%, whichever is greater|
|Home Health Care*||10% Coinsurance|
|Emergency Services||$50 Copay followed by 10% Coinsurance|
|Organ Transplants||Prior Approval|
|Skilled Nursing Services*||10% Coinsurance after $125 daily deductible|
|Not Covered||Eyeglasses, Hearing Aid, Infertility Treatment|
*Inpatient benefit limit of 180 days per calendar year including skilled nursing and home health visits.
Medical Evacuation Benefit
UIGRADCare will cover medical evacuation services in the event of illness or injury to students if necessary and adequate medical care cannot be provided at the location when the illness or injury occurs. Medical evacuation benefits cover expenses to the nearest appropriate medical facility. Pre-certification of medical evacuation services is required.
Repatriation benefits cover expenses incurred in returning the body to the person's place of residence in his or her home country including, but not limited to, the cost of embalming, the coffin, and transportation of the body.
All of the health plans offered through the University of Iowa, which are administered by Wellmark Blue Cross and Blue Shield of Iowa, provides coverage of medically necessary covered services associated with gender transition-related treatment.
Wellmark Blue Cross and Blue Shield of Iowa follows the national standards set forth by the World Professional Association for Transgender Health (WPATH) when deeming if a covered service is medically necessary.
Covered services, when ordered by a health professional and deemed medically necessary associated with gender transition-related treatment, may include the following:
- Hormone therapy;
- Mental health services; and
- Chest/breast and genital surgeries when ordered by a health professional.
Please contact Wellmark Blue Cross and Blue Shield of Iowa at 800-643-9724 for more information and to discuss the gender transition medical policy within the Interqual Prior Approval program to assure you have met all qualifications.
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.