UHC Surest Plan
Medical coverage options through Kaiser Permanente (California residents only) and UnitedHealthcare.
Plan Details
Network
Select Plus UHC Network
Administrator
UnitedHealthcare
Plan Type
Surest (PPO)
HSA Eligible
No
FSA Eligible
Yes
Eligibility
Active, full-time employees
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 | In-Network |
|---|---|
| Deductible (Individual/Family) | $0 |
| Out-of-Pocket Limit (Individual/Family) | $4,000 / $8,000 |
| 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 |
Deductible (Individual/Family)
- In-Network
- $0
Out-of-Pocket Limit (Individual/Family)
- In-Network
- $4,000 / $8,000
Preventive Visit
- In-Network
- $0
Virtual Visit
- In-Network
- $0
Office Visit
- In-Network
- $10 to $65
Virtual mental health visit
- In-Network
- $25
Mental health office visit
- In-Network
- $10
Urgent care visit
- In-Network
- $35
Emergency room visit
- In-Network
- $375
Basic diagnostic lab tests, x-rays and ultrasounds
- In-Network
- $0
Physical therapy (60 visits)
- In-Network
- $5 to $45
Maternity labor and delivery
- In-Network
- $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
- This plan utilizes the Select Plus UHC Network.
- No deductible.
- If you use an out-of-network provider, you will be responsible for any charges above the maximum allowed amount.