Wellmark Blue Cross / Blue Shield Plan Documents:

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 providersNot available without approved referral
Additional information
  • Pre-approval of inpatient admissions is required
  • Second surgical opinion is voluntary
  • Dependent child age limit - end of the year in which the individual turns 26 or unlimited if a full-time student or disabled

Preventive Care Services

Immunizations$0 copay
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 UI Health Care)

Hospital Services

Room and board, semi-private10% coinsurance after $125 daily deductible
Physicians services10% coinsurance
Inpatient/outpatient surgery & supplies10% coinsurance

Outpatient Services

Ambulance10% coinsurance
Allergy treatments$10 copay
Imaging and Lab10% coinsurance
Dental accident care10% coinsurance; treatment must be completed within 12 months of injury
Durable Medical Equipment (DME)10% coinsurance
Speech, occupational, respiratory, and physical therapy10% coinsurance
Office visit
Chiropractic visit
$10 copay
Mental health office visit0% coinsurance at UI Health Care or Wellmark Health Plan of Iowa Provider;
50% coinsurance out-of-network;
Out-of-network mental health and substance abuse is 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 transplantsPrior approval
Skilled Nursing Services*10% coinsurance after $125 daily deductible
Not CoveredEyeglasses, 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,out-of-network 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 Benefit

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.

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, cover medically necessary covered services associated with gender transition-related treatment.

Wellmark Blue Cross and Blue Shield of Iowa follow the national stanThe seconddards 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 ensure 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.