Back
UHC Surest Plan
Medical plan options provided through UnitedHealthcare.
Plan Details
Network
Select Plus UHC Network
Plan Type
Surest (PPO)
HSA Eligible
No
FSA Eligible
Yes
Premium Contributions
| Coverage Tier | Per-Paycheck Contribution |
|---|---|
| Employee Only | $14.48 |
| Employee + Spouse | $221.78 |
| Employee + Child(ren) | $156.21 |
| Employee + Family | $358.03 |
Employee Only
- Per-Paycheck Contribution
- $14.48
Employee + Spouse
- Per-Paycheck Contribution
- $221.78
Employee + Child(ren)
- Per-Paycheck Contribution
- $156.21
Employee + Family
- Per-Paycheck Contribution
- $358.03
Covered Services
| Service | Your Cost |
|---|---|
| Deductible (Individual/Family) | $0 |
| Out-of-Pocket Limit (Individual/Family) | $4,000 / $8,000 |
Deductible (Individual/Family)
- Your Cost
- $0
Out-of-Pocket Limit (Individual/Family)
- Your Cost
- $4,000 / $8,000
Coverage Details
| Service | Your Copays |
|---|---|
| Preventive Visit | $0 |
| Virtual Visit | $0 |
| Office Visit | $10 to $65 |
| Virtual mental health visit | $25 |
| Mental health office visit | $10 |
| Urgent care visit | $35 |
| Emergency room visit | $375 |
| Basic diagnostic lab tests, x-rays and ultrasounds | $0 |
| Physical therapy (60 visits) | $5 to $45 |
| Maternity labor and delivery | $625 to $1,600 |
Preventive Visit
- Your Copays
- $0
Virtual Visit
- Your Copays
- $0
Office Visit
- Your Copays
- $10 to $65
Virtual mental health visit
- Your Copays
- $25
Mental health office visit
- Your Copays
- $10
Urgent care visit
- Your Copays
- $35
Emergency room visit
- Your Copays
- $375
Basic diagnostic lab tests, x-rays and ultrasounds
- Your Copays
- $0
Physical therapy (60 visits)
- Your Copays
- $5 to $45
Maternity labor and delivery
- Your Copays
- $625 to $1,600
Pharmacy Benefits
| Tier | In-Network | Out-of-Network |
|---|---|---|
| Retail (30-day supply) – Tier 1 | $10 | Not covered |
| Retail (30-day supply) – Tier 2 | $35 | Not covered |
| Retail (30-day supply) – Tier 3 | $70 | Not covered |
| Retail (30-day supply) – Specialty | Copay based on tier level | Copay based on tier level |
| Mail Order (90-day supply) – Tier 1 | $25 | Not covered |
| Mail Order (90-day supply) – Tier 2 | $87.50 | Not covered |
| Mail Order (90-day supply) – Tier 3 | $175 | Not covered |
Retail (30-day supply) – Tier 1
- In-Network
- $10
- Out-of-Network
- Not covered
Retail (30-day supply) – Tier 2
- In-Network
- $35
- Out-of-Network
- Not covered
Retail (30-day supply) – Tier 3
- In-Network
- $70
- Out-of-Network
- Not covered
Retail (30-day supply) – Specialty
- In-Network
- Copay based on tier level
- Out-of-Network
- Copay based on tier level
Mail Order (90-day supply) – Tier 1
- In-Network
- $25
- Out-of-Network
- Not covered
Mail Order (90-day supply) – Tier 2
- In-Network
- $87.50
- Out-of-Network
- Not covered
Mail Order (90-day supply) – Tier 3
- In-Network
- $175
- Out-of-Network
- Not covered
Plan Notes
- You pay a flat dollar amount—or copay—for covered health care treatments and services, such as doctor’s office visits and prescription drugs.
- Once you hit your annual out-of-pocket maximum, the plan will cover 100% of the cost of covered services for the rest of the year.