Medical Benefits

We offer a high-deductible plan through UMR, a division of United Healthcare (UHC), with a Health Savings Account through Bank of America. UMR gives you the freedom to see any physician or other health care professional from the network, including specialists. You may also choose outside of network with reduced benefits.

**You must acknowledge affirmatively on the Tobacco-Free affidavit to receive the Tobacco-Free premium discount.

	United Healthcare PPO Network	Out-of-Network
Calendar Year Deductible (includes Rx) (Individual/Family)	$2,000/$4,000	$5,000/$10,000
Calendar Year Out of Pocket Maximum Includes deductible, coinsurance and copays if applicable. (Individual/Family)	$3,000/$6,000	$10,000/$20,000
Services
Emergency Room/Ambulance	100% After Deductible	100% After Deductible
Urgent Care	100% After Deductible	70% After Deductible
Hospital Services other than Mental Health and Substance Abuse	100% After Deductible	70% After Deductible
Inpatient and Outpatient Physician Charges	100% After Deductible	70% After Deductible
Outpatient Services/Outpatient Physician Charges	100% After Deductible	70% After Deductible
Outpatient Lab and X-Ray Charges	100% After Deductible	70% After Deductible
Outpatient Surgery/Surgeon Charges	100% After Deductible	70% After Deductible
Physician and Specialist Office Visit	100% After Deductible	70% After Deductible
Physician Office Services (Office Surgery)	100% After Deductible	70% After Deductible
Therapy Services – Outpatient Hospital and Office Therapy	100% After Deductible	70% After Deductible
Preventative Services Routine Care Benefits
Routine Physical Exams at Appropriate Ages	100%, Deductible Waived	70% after deductible
Immunization (Including Flu Vaccine)	100%, Deductible Waived	70% after deductible
Routine Diagnostic Tests, Lab and X-Rays	100%, Deductible Waived	70% after deductible
Routine Mammograms and Breast Exams: Limited to 1 exam per year	100%, Deductible Waived	70% after deductible
Routine Pelvic Exams and Pap Test: Limited to 1 exam per year	100%, Deductible Waived	70% after deductible
Routine PSA and Prostate Exams: Limited to 1 exam per year	100%, Deductible Waived	70% after deductible
Routine Colonoscopy, Sigmoidoscopy and Similar Routine Surgical Procedures	100%, Deductible Waived	70% after deductible
Limits Apply as Follows:
Physical	20 visits per year	20 visits per year
Occupational	20 visits per year	20 visits per year
Speech	20 visits per year	20 visits per year
Pulmonary	20 visits per year	20 visits per year
Cardiac 36 visits per year	36 visits per year	36 visits per year

Downloads

Summary of Benefits

Summary Plan Description

Teladoc

Your pharmacy benefits will be administered by RxBenefits in partnership with OptumRx. The RxBenefits service model delivers enhanced safety, better cost savings, and top-notch customer service. With OptumRx, you’ll have access to a massive network of more than 64,000 pharmacies nationwide.

If you need to fill a prescription before your card arrives, simply provide the following, along with your member number or Social Security number, to the pharmacy:

RXBIN: 610011 RXBPCN: IRX
RXGRP: RXBENHOSP
Pharmacy Member Services: 800.334.8134
Pharmacist Helpdesk: 800.880.1188

Download the OptumRx App now from the Apple App Store or Google Play.

Participating Pharmacy	Retail (30 Day Supply)	Retail (90 Day Supply)	Mail Services (90 Day Supply)
Maximum Day Supply Allowed	31	90	90
Tier 1/Generic Copay	$10	$25	$25
Tier 2/Brand Copay	$35	$87.50	$87.50
Tier 3/Non-Preferred	$60	$150	$150
Generic Specialty Medication Copay	$10 with a maximum 30 day supply allowed per fill	$10 with a maximum 30 day supply allowed per fill	$10 with a maximum 30 day supply allowed per fill
Formulary Specialty Medication Copay	$100 with a 30 day supply allowed per fill	$100 with a 30 day supply allowed per fill	$100 with a 30 day supply allowed per fill
Non-Formulary Specialty Medication Copay	$300 with a 30 day supply allowed per fill	$300 with a 30 day supply allowed per fill	$300 with a 30 day supply allowed per fill


Annual Medical / Rx Combined Deductible	$2,000 per Individual, $4,000 per Family beginning every January 1st. Once you have met this amount, you will pay the above copays until the end of the benefit year, December 31st, or until you reach the Out-of-Pocket maximum as stated below.
Annual Medical / Rx Combined Out-of-Pocket Maximum	$3,000 per Individual, or $6,000 per Family beginning every January 1st. Once you have met this amount, you will pay $0 copay until the end of the benefit year, December 31st.