New! Surest Medical Plan
Available to employees in Georgia, North Carolina, and Texas.
| PLAN FEATURES |
UHC SUREST
In-Network
|
|---|---|
| Plan Year Deductible | $0 |
| Medical Out-of-Pocket Maximum – Includes deductibles and/or copays |
$5,500 Indiv. $11,000 Fam. |
| Rx Out-of-Pocket Maximum – Includes deductibles and/or copays | Included in the medical out-of-pocket max. |
| Member Coinsurance | N/A |
| Preventive Care – 1 exam every Plan Year | Covered at 100% |
| Primary Care Physician | $25 – $130 copay |
| Specialist | $25 – $130 copay |
| Virtual Care – Primary and Urgent | $0 copay |
| Virtual Care – Mental Health and Substance Use Disorder | $25 – $70 copay |
| Virtual Care – Specialty | $0 – $130 copay |
| Lab and X-ray Services | $0 copay |
| Physical/Occupational/ Speech Therapy | $15 – $130 copay |
| Urgent Care | $80 copay |
|
Emergency Room:
- Emergency Care
- Non-Emergency Care
|
$900 copay |
| Hospital Services | $400 – $3,500 copay |
| PRESCRIPTION DRUGS | |
| Pharmacy Deductible | $250 per member |
| Retail (Up to 31-day supply) | After ded. is met, then: |
| Generic | $10 copay |
| Preferred Brand | 30% after ded. ($40 min., $75 max.) |
| Non-Preferred Brand | 30% after ded. ($75 min., $150 max.) |
| Retail and Mail Order (Up to 90-day supply) | After ded. is met, then: |
| Generic | $30 copay |
| Preferred Brand | 30% after ded. ($120 min., $225 max.) |
| Non-Preferred Brand | 30% after ded. ($225 min., $450 max.) |