Copayments, Coinsurance, Deductibles - UIChoice

Health care under the UIChoice plan may be obtained from any provider you wish. The provider you choose determines the plan benefit level and how much you pay.

Office Visits

Office visits with Level 1 providers have a $5.00 co-payment. Level 2 providers have a $20.00 co-payment. Level 3 providers have 40% co-insurance.

Routine Annual Physical Examination, Preventive care Services, Well Child Care

There is no physician charge or copayment for a routine annual physical examination from a level 1 or 2 or participating level 3 provider, and 40% coinsurance applies for a Level 3 non-participating provider. There is a charge for non-preventive care labs, tests, and imaging on all levels. Preventive care services are not subject to coinsurance if received from a Level 1 or Level 2 or participating Level 3 provider.  Level 3 non-participating providers are subject to 40% coinsurance.

There is no copayment or coinsurance for well-child care (children up to seven years of age).

Emergency Care

When care is necessitated by an emergency, the individual's share of the emergency room costs will include a $50 copayment and 10% of the charges with Level 1 and 20% of the charges with Level 2 providers. Level 3 providers will be the same unless the visit is not coded as an emergency, then there will be a $50 copayment and 40% coinsurance. The $50 copayment is waived regardless of the provider level if you are admitted to the hospital.  The $50 copayment is waived if you are admitted to the hospital.

Hospital Services

When an individual is admitted to a hospital, the individual will pay a $400 deductible for level 1 providers, $600 deductible for level 2 providers, and an $800 deductible for level 3 providers. After the deductible is paid, the individual will pay 10% of the charges for Level 1 providers, 20% of the charges for Level 2 providers, and 40% of the charges for Level 3 providers, subject to the out-of-pocket maximum limits.

The coinsurance for outpatient hospital services including outpatient surgery, physician care, supplies, labs & imaging is 10% for level 1 providers, 20% for level 2 providers, and 40% for Level 3 providers - again, subject to the out-of-pocket maximum limits. A copayment may also apply.

Durable Medical Equipment

Insureds will pay 20% for durable medical equipment.

This website provides a general summary of the basic benefit provisions and is not a substitute for the Benefit Booklet. If there are any inconsistencies between this summary and the benefit booklet, the booklet will prevail. Please refer to the Benefit Booklet for exact benefits, exclusions, and limitations or contact Wellmark’s customer service at 1-800-622-0043.