The UIGRADCare plan provisions chart below should only be used as a general guide. Please refer to the UIGRADCare Coverage Manual (pdf) for further information. If the information in this summary chart differs from the coverage manual, the UIGRADCare Wellmark Coverage Manual Document will govern.
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 reach your deductible.
OPM
Most you pay for covered services in plan year after paying deductibles, copays & coinsurance.
UIGRADCare Plan Provisions
| Coinsurance | 10% | |
| 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 | |
| Additional information |
| |
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-private | 10% coinsurance after $125 daily deductible |
| Physicians services | 10% coinsurance |
| Inpatient/outpatient surgery & supplies | 10% coinsurance |
Outpatient Services
| Ambulance | 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 (DME) | 10% coinsurance |
| Speech, occupational, respiratory, and physical therapy | 10% coinsurance |
| Office visit Chiropractic visit | $10 copay |
| Mental health office visit | 0% 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 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; 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.
UIGRADCare Plan Documents:
UIGRADCare Plan Provisions
| Annual out-of-pocket maximum (OPM) | |
|---|---|
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.