SHIP Plan Details

The SHIP plan provisions chart below should only be used as a general guide. Please refer to the SHIP Coverage Manual (pdf) for further information. If the information provided in this summary chart differs from the coverage manual, the SHIP Wellmark Coverage Manual Document will govern.

Common Medical Plan Terms and Definitions

Deductible

Amount of money you pay out-of-pocket for care before plan begins to pay for benefits.

Copay

Flat dollar amount you'll pay for covered services at the time of service.

Coinsurance

Percentage you pay for covered services after you've reached your deductible.

OPM

Most you pay for covered services in plan year after paying deductibles, copays & coinsurance.

Alliance Select PPO Plan Provisions

	Alliance Select PPO
Annual Deductible	$500 Single \| $1,000 Family
Annual out-of-pocket maximum (OPM)	Medical + Pharmacy OPM $5,000 Single \| $10,000 Family
Coinsurance	20% coinsurance for in-network providers 40% coinsurance for out-of-network providers

^{1) You must pay all the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible.

2) The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they must meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Premiums, balance-billed charges, and health care this plan doesn't cover do not count toward the out-of-pocket limit.}

Office Visits, Services, and Hospital Stay Provisions
	In-Network Providers	Out-of-Network providers
Preventive Care³	Plan pays 100%	40% coinsurance
Primary Care and Specialist Care Office Visits⁴	Primary Care: $25 copay Specialist visit: $50 copay per provider per date of service	40% coinsurance
Mental Health Office Visits	$0 copay per provider per date of service	40% coinsurance
Chiropractic Care	$25 copay per provider per date of service	40% coinsurance
Speech, Occupational, and Physical Therapies	$25 copay for primary care per provider per date of service	40% coinsurance
Routine Eye & Hearing Exams	Not covered under the plan
UI QuickCare	$25 copay per provider per date of service	40% coinsurance
Urgent Care	$25 copay per provider per date of service	40% coinsurance
Emergency Room Visits	$150 copay per visit for facility and physician(s) combined	$150 copay per visit for facility and physician(s) combined
Ambulance⁶	20% coinsurance, after deductible	20% coinsurance, after deductible
Inpatient Surgery⁷	20% coinsurance after deductible	40% coinsurance
Outpatient Surgery	Facility Fee - 20% coinsurance Physician/Surgeon fees -20% coinsurance	Facility Fee - 40% coinsurance Physician/Surgeon fees -40% coinsurance
Imaging and Lab Work⁸	20% coinsurance after deductible	40% coinsurance
Durable Medical Equipment	20% coinsurance after deductible	40% coinsurance

^{3) Preventive care includes immunizations and well-child care (up to age 7), routine physicals, gynecological exams, and mammogram exams per calendar year. You may find a complete list of covered preventive services at the HealthCare.gov.

4) You may see the specialist you choose without a referral.

6) For covered non-emergent situations, out-of-network ambulance services are NOT reimbursed at the in-network level. Benefits for non-participating ambulance providers are based on actual billed charges.

7) Pre-approval of inpatient admissions is required; Second surgical opinion is voluntary;

8) Imaging (CT/PET scans, MRIs) and Labs are diagnostic tests such as x-rays and blood work.}

3-tier Prescription Drug Plan (Blue Rx Value Plus)

You must consult the Wellmark Blue Rx Value Plus drug list to determine if a drug is covered. You are covered for drugs on this list. If a drug is not on the list, it is not covered.

To find where your drug falls on the Blue Rx Value Plus formulary list, please visit Wellmark.com,

Select "Member Resources" and choose the "Prescriptions & Drug Lists" menu item.
Scroll down the following webpage until you find the link "Blue Rx Value Plus." Select this link to access the specific formulary drug list.
You may now search for your drug name.

Tier of drug	coinsurance amount
Tier 1: Generic Drugs	25% coinsurance
Tier 2: Preferred Name Brand Drugs	30% coinsurance
Tier 3: Non-preferred Name Brand Drugs	50% coinsurance

Specialty Drugs:

Injectable specialty drugs are covered under the health plan.
Oral specialty drugs are covered under the drug plan, and the cost share is based on tier placement in the Blue Rx Value Plus formulary list.

Other Covered Services and Excluded Services

Limitations may apply to these services. This is not a complete list.

Applied Behavior Analysis therapy applies to home health care limits.
Bariatric surgery
Chiropractic care
Most coverage is provided outside the U.S.
Private-duty nursing - short-term intermittent home skilled nursing

These are services your plan generally does NOT cover. Check your policy or plan document for more information and a list of any other excluded services.

_{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.}