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.
Plan Provisions
| SHIP | UIGRADCare | |
|---|---|---|
| PROVIDERS |
You may see any provider you wish nationwide. (Wellmark Classic Blue network) |
Must use Student Health or UIHC Providers. Providers outside the UI Health Care network will not be covered by the plan. |
| DEDUCTIBLE | $300 (Applies to inpatient admission only and is taken once per admission.) |
$125 daily deductible followed by 10% coinsurance |
| COINSURANCE |
10% |
10% |
| COPAY | Office Visit: $10 Emergency Room: $50 Other Services: $15 |
Office Visit & Other Services: $10 Emergency Room: $50 |
| OUT-OF-POCKET MAXIMUM (OPM) |
Health: $1,700 single / $3,400 family. Prescription Drugs: $1,000 single / $2,000 family |
UIHC Providers: The Provider and Drug OPM's accumulate separately. |
| PRE-APPROVAL of INPATIENT ADMISSIONS | Pre-approval is REQUIRED for both SHIP and UIGRADCare for Inpatient Admissions. | |
| SECOND SURGICAL OPINION | Voluntary for both SHIP and UIGRADCare | |
| DEPENDENT CHILD AGE LIMIT | Effective Jan. 1, 2021, the dependent child is covered up to age 26. SHIP or UIGRADCare will not allow coverage for full-time student dependent child(ren) after age 26. |
|
Preventive Care Services
| SHIP | UIGRADCARE | |
|---|---|---|
| IMMUNIZATIONS | $0 | UI Health Care: $0 Out-of-Network: Not covered |
| WELL-CHILD CARE (TO AGE 7) |
$0 | UI Health Care: $0 Out-of-Network: Not covered |
| GYNECOLOGICAL PELVIC EXAMS AND PAP SMEARS |
$0 (one per calendar year, unless medically necessary) |
UI Health Care: $0 |
| ROUTINE PREVENTIVE EXAMS |
$0 (one per calendar year, unless medically necessary. Mammograms are unlimited.) |
UI Health Care: $0 (unlimited preventive exams and mammograms) Out-of-Network: Not covered |
| ROUTINE EYE & HEARING EXAMS | Not Covered. | UI Health Care: $0 Other: $10 copay |
Hospital Services
| SHIP | UIGRADCare | |
|---|---|---|
| ROOM & BOARD (SEMI-PRIVATE) |
$300 deductible, followed by 10% coinsurance |
$125 daily deductible, followed by 10% coinsurance |
| PHYSICIANS SERVICES | 10% coinsurance | 10% coinsurance |
| INPATIENT/OUTPATIENT SURGERY & SUPPLIES |
10% coinsurance | 10% coinsurance |
Outpatient Services
| SHIP | UIGRADCare | |
|---|---|---|
| AMBULANCE | $15 copay | 10% coinsurance |
| ALLERGY TREATMENTS | $15 copay | $10 copay |
| IMAGING AND LAB | $15 copay | 10% coinsurance |
| DENTAL ACCIDENT CARE | $15 copay; Treatment must be completed within 12 months of injury. |
10% coinsurance Treatment must be completed within 12 months of injury. |
| DURABLE MEDICAL EQUIPMENT | $15 copay | 10% coinsurance |
| SPEECH, OCCUPATIONAL, RESPIRATORY, AND PHYSICAL THERAPY | $15 copay | 10% coinsurance |
| OFFICE VISIT, CHIROPRACTOR VISIT | $10 copay | $10 copay |
| MENTAL HEALTH OFFICE VISIT | $10 copay | 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 |
Tier/what you pay per tier: |
$7 or 25% coinsurance, whichever is greater |
| HOME HEALTH CARE* | $5 copay; maximum of 30 days/calendar year | 10% coinsurance |
| EMERGENCY SERVICES | $50 copay | $50 copay followed by 10% coinsurance |
| ORGAN TRANSPLANTS | Prior approval; cornea, kidney coverage only | Prior approval |
| SKILLED NURSING SERVICES* | 10% coinsurance; Maximum of 30 visits per calendar year | 10% coinsurance after $125 daily deductible |
| NOT COVERED | Eyeglasses, Hearing Aid, Infertility Treatment, Travel Vaccinations and Immunizations | Eyeglasses, Hearing Aid, Infertility Treatment |
*Inpatient benefit limit of 180 days per calendar year including skilled nursing and home health visits.
Transgender Coverage
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.