| PLAN | SHIP | UISELECT | UICHOICE |
|---|---|---|---|
| Providers | Any Provider | Level 1 - All UI Health Care providers Level 2 - Blue Access Network Level 3 - not covered | Level 1 - All UI Health Care providers Level 2 - Blue Choice Network Level 3 - BlueCard Network |
| Deductible | None - visit inpatient deductible below | Level 1 - Level 2 - | None - visit inpatient deductible below |
| Inpatient Care Deductible | $300 followed by 10% coinsurance | N/A - see above | Level 1 - $400 followed by 10% coinsurance Level 2 - $600 followed by 10% coinsurance Level 3 - $800 followed by 40% coinsurance |
| Out-of-Pocket Maximum (OPM) | Single: $1,700 Family: $3,400 | Employee: $2,000 Family: $3,400 | Employee: $1,700 Family: $3,400 Non-participating providers: |
| Coinsurance | 10% | Level 1 - 15% Level 2 - 25% | Level 1 - 10% Level 2 - 20% Level 3 - Varies based on location & service |
| Preventive Care includes preventive exams, gynecological exams, immunizations, mammograms & well-child care | $0 copay (gyno and routine physical exams are one per calendar year unless medically necessary) | $0 copay | $0 copay |
| Doctor on Demand | N/A | $0 copay | $0 copay |
| UI QuickCare | $10 copay | Level 1 - $5 copay Level 2 - N/A | Level 1 - $5 copay Level 2 - N/A Level 3 - N/A |
| UI UrgentCare | $10 copay | Level 1 - $10 copay Level 2 - N/A | Level 1 - $10 copay Level 2 - N/A Level 3 - N/A |
| Emergency Room Services (Copay waived if admitted) | $50 copay | Level 1 & 2 - $100 copay followed by 10% coinsurance | Level 1, 2 & 3 - $100 copay followed by 10% coinsurance |
| Routine Eye and Hearing Exams | Not Covered | Level 1 - Level 2 - | Level 1 - $10 copay Level 2 - $25 copay Level 3 - 50% coinsurance |
| Office Visits | $10 copay (includes Chiropractic) | Level 1 - Primary Care: Level 2 - Primary Care: (primary care will apply to chiropractic care, physical, speech & occupational therapies) | Level 1 - $10 copay Level 2 - $25 copay Level 3 - 50% coinsurance |
| Mental Health Care Visit | $10 copay | Level 1 - $10 copay Level 2 - $10 copay | Level 1 - $0 copay Level 2 - $0 copay Level 3 - 50% coinsurance |
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 apply. If there are any discrepancies between the information contained herein and the official plan documents, the plan documents will govern.