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Faculty, Professional and Scientific, Merit Supervisory Exempt Staff  

Faculty, Staff, and Merit Supervisory/Exempt
Health Insurance Benefits

Effective January 1, 2013 through December 31, 2014

Plan Provisions : Office Care : Hospital Services : Miscellaneous

Plan Provisions


Care Providers

Any Provider:  The provider or facility category you use determines the plan benefit level.  This is one plan with three different benefit levels:

Benefit Providers covered at this level


Level 1     University of Iowa Hospitals and Clinics, Carver College of Medicine (CCOM) and UI Community Medical Services Clinics (CMSC)

Level 2     Blue Choice Network Providers not included in Level 1

Level 3     Any provider outside of Level 1 or 2

Blue Cross/Blue Shield (BC/BS) providers can result in lower out-of-pocket costs.  For non-BC/BS providers, insured pays charges over the maximum allowable fee.
Deductible Single/Family


Co-insurance Percentage

Level 1-10%
Level 2-10%
Level 3-40%

Out-of-Pocket Limit

Combined OPM for Level 1 & Level 2 Services-$1,700 / $3,400;

OPM for Level 3 Services-$2,000 / $4,000;

OPM for prescription drugs-$1,100 / $2,200
Pre-existing Condition Waiting Period


Pre-approval of Inpatient Admissions

Required (Subscriber must obtain approval from BC/BS)

Domestic Partner coverage for same and opposite-sex Domestic Partners Available
Second Surgical Opinion



Handled the same as all other medical claims

Organ Transplants Prior approval required
Dependent Child Age Limit

End of the year they turn 26; unlimited if a full time single student or disabled before age 27

Emergency Defined as: a medical condition that a prudent layperson (with an average knowledge of health and medicine) could reasonably expect to result in serious jeopardy to a person’s health in the absence of immediate medical attention.


Office Care


Office Calls

Level 1-$5 co-pay

Level 2-$20 co-pay

Level 3-40% coinsurance
Routine Physicals Level 1 & 2 & 3 - $0 co-pay
Imaging and Labs Level 1 & 2-10% coinsurance
Level 3-40% coinsurance
Well Child Care Level 1 & 2 & 3 - $0 co-pay
Immunizations Level 1 & 2 & 3-$0 co-pay
Routine Eye /
Hearing Exam
Level 1-$5 co-pay
Level 2-$20 co-pay
Level 3-40% coinsurance


Hospital Services


Emergency Room Care

Level 1 & Level 2-$50 co-payment  (waived if admitted) followed by 10% coinsurance

Level 3-Same as Level 1 or 2 if coded as an emergency; if not coded as an emergency, $50 co-payment followed by 40% coinsurance
Room and Board

Level 1-$400 deductible
Level 2-$600 deductible
Level 3-$800 deductible

semi-private room; followed by coinsurance
Inpatient and Outpatient Surgery, Physician Care, Supplies, Labs, & Imaging

Level 1-10% coinsurance
Level 2-20% coinsurance
Level 3-40% coinsurance


Miscellaneous Services


Prescription Drugs

3-tiered coinsurance plan;

  • 1-Generic drugs have 0% coinsurance; provided at no cost to plan member;
  • 2-Name-brand Wellmark Formulary drugs have 30% coinsurance;
  • 3-Name-brand non-formulary drugs have 50% coinsurance

Level 1-no provider
Level 2-$20 co-pay
Level 3-40% coinsurance

Hearing Aid

20% coinsurance;
maximum benefit of $2,000 every 5 years

Outpatient Physical Therapy, Speech, Occupational, and Respiratory Therapy

Level 1 & 2-10% coinsurance
Level 3-40% coinsurance

Home Health Care/Ambulance/Hospice

Level 1 & 2-10% coinsurance
Level 3-40% coinsurance

Durable Medical Equipment 20% coinsurance
Infertility ($25,000 lifetime Maximum)

Level 1-10% coinsurance
Level 2-30% coinsurance
Level 3-40% coinsurance

Does not count against OPM

Imaging and Lab to Third Party Providers

Level 1 & 2-10% coinsurance
Level 3-40% coinsurance


Questions? Need Help?

If you have questions or concerns regarding the enrollment process, please contact:

University Benefits
120-40 USB


Phone: 319-335-2676 or
877-830-4001 (toll free)

Fax: 319-335-2776

Page last updated 2/2012