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 - 
Employee: $400
Family: $800

Level 2 - 
Employee: $800
Family: $1,600

 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:
Employee: $2,000 / Family: $4,000
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: 
$10 copay
Level 1 - Specialist Care:
$20 copay

Level 2 - Primary Care:
$35 copay
Level 2 - Specialist Care:
$50 copay

(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

Gender Transition

All of the health plans offered through the University of Iowa provide benefits for medically necessary covered services associated with gender transition when ordered by a health professional. Please contact Wellmark Blue Cross and Blue Shield at 800-643-9724 for more information and to discuss the gender transition medical policy. 

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.