Medical Plan Highlights
The following benefits apply to students and their dependents enrolled in the University-sponsored Student Health Benefit Plan. This Quick Reference Benefit Chart is intended as a guide. For plan details, refer to the Office of Student Health Benefit's website.
Deductibles
| Deductible and Out-of-Pocket | In-Network | Out-of-Network |
| Lifetime maximum | Unlimited |
| Plan year deductible | None | $200 per person; $600 family |
Plan year medical out-of-pocket maximum
(Non-covered charges and charges in excess of the allowed amount do not apply to the out-of-pocket maximum) | $2,500 per individual / $5,000 per family |
| Plan year prescription out-of-pocket maximum | $300 per individual / $600 per family (for all covered prescription) |
Preventative Care
| Covered Services | In-Network | Out-of-Network |
| Routine physical and eye examinations | 100% coverage | 80% coverage after deductible |
| Well-child care | 100% coverage | 100% coverage |
| Prenatal and postnatal care | 100% coverage | 100% coverage |
| Immunizations | 100% coverage | 80% coverage after deductible |
Office Visits
| Covered Services | In-Network | Out-of-Network |
| Illness or injury | $10 copayment | 80% coverage after deductible |
| Allergy injections | $10 copayment | 80% coverage after deductible |
| Physical, occupational and speech therapy | $10 copayment | 80% coverage after deductible |
| Chiropractic care (for neuromusculoskeletal conditions only) | $10 copayment | 80% coverage after deductible |
| Mental/Chemical health care | $10 copayment | 80% coverage after deductible |
Convenience Care
| Covered Services | In-Network | Out-of-Network |
| Convenience clinics (retail clinics) | $5 copayment | 80% coverage after deductible |
Emergency Care
| Covered Services | In-Network | Out-of-Network |
| Urgently needed care at an urgent care clinic or medical center | $10 copayment | 80% coverage after deductible |
| Emergency care at a hospital ER | $40 copayment | $40 copayment |
| Ambulance | 80% coverage | 80% coverage |
Inpatient Hospital Care
| Covered Services | In-Network | Out-of-Network |
| Illness or injury | 100% coverage | 80% coverage after deductible |
| Mental/Chemical health care | 100% coverage | 80% coverage after deductible |
Outpatient Care
| Covered Services | In-Network | Out-of-Network |
| Scheduled outpatient procedures | 100% coverage | 80% coverage after deductible |
| Outpatient Magnetic Resonance Imaging (MRI) and Computer Tomography (CT) | 100% coverage | 80% coverage after deductible |
Durable Medical Equipment
| Covered Services | In-Network | Out-of-Network |
| Durable medical equipment and prosthetic devices | 80% coverage | 80% coverage |
Prescription Drugs
Retail Pharmacy Copayment for 31-day supply
| Medication Type | In-Network | Out-of-Network |
| Generic Preferred** | $10 copayment | 80% coverage after deductible |
| Brand Preferred** | $25 copayment | 80% coverage after deductible |
| Non-Preferred** | $50 copayment | 80% coverage after deductible |
Mail Order Pharmacy & Retail Pharmacy for 90-day supply
| Medication Type | In-Network | Out-of-Network |
| Generic Preferred** | $20 copayment | No coverage |
| Brand Preferred** | $50 copayment | No coverage |
| Non-Preferred** | $100 copayment | No coverage |
Important Notes
**When a member purchases a brand drug when a chemically equivalent generic is available, the member will pay the brand copay and the difference in cost between the brand drug and the generic drug, regardless of whether “dispense as written” is on the prescription .
- Your out-of-pocket costs depend on the network status of your provider . To check status, call Blue Cross customer service or visit bluecrossmn.com/umnga.
- UMD Graduate Assistants and their adult dependents do not pay a copayment for available services at UMD Health Services
- This is only a summary . Read your benefit booklet for more information about what is and isn’t covered . Services that aren’t covered include those that are cosmetic, investigative, not medically necessary or covered by workers’ compensation or no-fault insurance
Lowest out-of-pocket costs: in-network providers
Highest out-of-pocket costs: out-of-network nonparticipating providers (You are responsible for the difference between Blue Cross’ allowed amount and the amount billed by nonparticipating providers . This is in addition to any applicable deductible, copay or coinsurance . Benefit payments are calculated on Blue Cross’ allowed amount, which is typically lower than the amount billed by the provider .)
For more information, visit Blue Cross Blue Shield's website or call Blue Cross customer service at the number on the back of your member ID card