SHIP and UIGRADCare Comparison

The plan provisions chart comparison should be used as a general guide only. Please refer to the SHIP and/or UIGRADCare Coverage Manuals for further information. If the information provided in this summary chart differs from the coverage manual, the SHIP and/or UIGRADCare 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.

Coinsurance

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

Copay

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

OPM

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

Plan Provisions

SHIP vs. UIGRADCare Plan Provisions
	SHIP	UIGRADCare
PROVIDERS	In-network providers: Alliance Select PPO	Must use Student Health or UI Health Care Providers. The plan will not cover providers outside the UI Health Care network.
DEDUCTIBLE	$500 single/year $1,000 family/year	n/a
COINSURANCE	20% in-network 40% out-of-network	10% in-network
COPAY	Primary care office visit: $25 copay for in-network, 40% out-of-network Specialist office visit: $50 copay for in-network, 40% out-of-network Emergency room: $150 copay	Office visits and other services: $10 copay Emergency room: $50 copay
OUT-OF-POCKET MAXIMUM (OPM)	Health: $5,000 single / $10,000 family	UI Health Care Providers: $1,000 single / $1,700 family Prescription Drugs: $1,000 single / $1,700 family _{The Provider and Drug OPM's accumulate separately.} _{Premiums, balance-billed charges, and health care} _{from providers that UIGRADCare does not cover will} _{not count toward your OPM.}
PRE-APPROVAL of INPATIENT ADMISSIONS	Pre-approval is REQUIRED for both SHIP and UIGRADCare for inpatient admissions.
DEPENDENT CHILD AGE LIMIT	Effective Jan. 1, 2021, the dependent child is covered up to age 26. SHIP or UIGRADCare will not allow coverage for a full-time student dependent child(ren) after age 26.

Preventive Care Services

SHIP and UIGRADCare Preventive Care Comparison
	SHIP in-network	SHIP out-of-network	UIGRADCARE
IMMUNIZATIONS	$0 copay	40% coinsurance	UI Health Care: $0 Out-of-Network: Not covered
WELL-CHILD CARE (TO AGE 7)	$0 copay	40% coinsurance	UI Health Care: $0 Out-of-Network: Not covered
GYNECOLOGICAL PELVIC EXAMS AND PAP SMEARS	$0 copay _{(one per calendar year unless} _{medically necessary)}	40% coinsurance _{(one per calendar year unless} _{medically necessary)}	UI Health Care: $0 Lab Tests/Materials: 10% coinsurance _{(unlimited Gynecological visits)} Out-of-Network: Not covered
ROUTINE PREVENTIVE EXAMS	$0 copay _{(one per calendar year, unless} _{medically necessary. Mammograms} _{are unlimited.)}	40% coinsurance _{(one per calendar year, unless} _{medically necessary. Mammograms} _{are unlimited.)}	UI Health Care: $0 _{(unlimited preventive exams and mammograms)} Out-of-Network: Not covered
ROUTINE EYE AND HEARING EXAMS	Not covered	Not covered	UI Health Care: $0 Other: $10 copay

Hospital Services

Hospital Services
	SHIP in-network	SHIP out-of-network	UIGRADCare
ROOM & BOARD (SEMI-PRIVATE)	$500 deductible, followed by 20% coinsurance	$500 deductible, followed by 20% coinsurance	$125 daily copayment, followed by 10% coinsurance
PHYSICIANS SERVICES	20% coinsurance	40% coinsurance	10% coinsurance
INPATIENT/OUTPATIENT SURGERY & SUPPLIES	20% coinsurance	40% coinsurance	10% coinsurance

Outpatient Services

Outpatient Services
	SHIP in-network	SHIP Out-of-network	UIGRADCare
	The deductible must be met before the insurance covers the cost. Coinsurance applies after meeting the deductible.		N/A
AMBULANCE	20% coinsurance	40% coinsurance	10% coinsurance
IMAGING AND LAB	20% coinsurance	40% coinsurance	10% coinsurance
DURABLE MEDICAL EQUIPMENT	20% coinsurance	40% coinsurance	10% coinsurance
SPEECH, OCCUPATIONAL, AND PHYSICAL THERAPY	$25 copay $50 copay for specialist	40% coinsurance	10% coinsurance
OFFICE VISIT	Primary Care Provider: $25 copay Specialist Provider: $50 copay	40% coinsurance	$10 copay
MENTAL HEALTH OFFICE VISIT	$0 copay	40% coinsurance	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 limited to 50 visits per calendar year}
PRESCRIPTION DRUGS	Blue Rx Value Plus Formulary Tier 1 drugs: 25% coinsurance Tier 2 drugs: 30% coinsurance Tier 3 drugs: 50% coinsurance		Blue Rx Complete Formulary $7 or 25% coinsurance, whichever is greater
EMERGENCY SERVICES	$150 copay	$150 copay	$50 copay followed by 10% coinsurance
NOT COVERED	Eyeglasses, hearing aid, infertility treatment, travel vaccinations and immunizations		Eyeglasses, hearing aid, infertility treatment

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_{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.}