Provisions
| SHIP | UIGRADCare | |
|---|---|---|
| Coinsurance Percentage | 10% | 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 Out of Network Providers | Individual is responsible for charges above the maximum allowable fee | Not available without approved referral |
| 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 Services
| SHIP | UIGRADCare | |
|---|---|---|
| Immunizations | $0 copay | $0 copay |
| Well-Child Care (to age 7) | $0 copay | $0 copay |
| Gynecological Pelvic Exams and Pap Smears | $0 copay (1 per calendar year unless medically necessary) |
$0 copay (lab tests and materials 10% coinsurance) |
| Routine Preventive Exams | $0 copay (1 per calendar year unless medically necessary) |
$0 copay (lab tests and materials 10% coinsurance) |
| Routine Eye & Hearing Exam | Not covered | $10 copay ($0 copay at UIHC) |
Hospital Services
| SHIP | UIGRADCare | |
|---|---|---|
| Room and Board Semi-private | 10% coinsurance after $300 deductible | 10% coinsurance after $125 daily deductible |
| 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 and what you pay per tier: Tier 1: 25% Tier 2: 30% Tier 3: 50% Tier 4: 50% |
$7 or 25%, 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.