United Healthcare Surest PPO Plan

United Healthcare Surest · PPO

Medical benefits are provided through Credence BCBS, United Healthcare Surest, and Kaiser (California Employees Only).

UNITED HEALTHCARE SUREST PPO PLAN

Plan Details

Carrier

United Healthcare Surest

Plan Type

PPO

HSA Eligible

Healthcare FSA Eligible

Yes

Who Can Enroll

All benefits-eligible employees

Monthly Contributions

Coverage Tier	Under $75K	$75K - <$125K	$125K+
Employee Only	$174.14	$208.16	$270.24
Employee + Spouse	$424.66	$543.43	$721.83
Employee + Child(ren)	$345.59	$442.24	$587.43
Employee + Family	$563.66	$721.30	$958.09

Employee Only

Under $75K: $174.14
$75K - <$125K: $208.16
$125K+: $270.24

Employee + Spouse

Under $75K: $424.66
$75K - <$125K: $543.43
$125K+: $721.83

Employee + Child(ren)

Under $75K: $345.59
$75K - <$125K: $442.24
$125K+: $587.43

Employee + Family

Under $75K: $563.66
$75K - <$125K: $721.30
$125K+: $958.09

Deductible, Out-of-Pocket & Coinsurance

Feature	In-Network	Out-of-Network
Employee	$0	$0
Family	$0	$0
Pharmacy Deductible	N/A	N/A
Coinsurance	N/A	N/A
Annual Out-Of-Pocket Maximum - Employee	$6,250	$12,500
Annual Out-Of-Pocket Maximum - Family	$12,500	$25,000

Employee

In-Network: $0
Out-of-Network: $0

Family

In-Network: $0
Out-of-Network: $0

Pharmacy Deductible

In-Network: N/A
Out-of-Network: N/A

Coinsurance

In-Network: N/A
Out-of-Network: N/A

Annual Out-Of-Pocket Maximum - Employee

In-Network: $6,250
Out-of-Network: $12,500

Annual Out-Of-Pocket Maximum - Family

In-Network: $12,500
Out-of-Network: $25,000

Covered Services

Service	In-Network	Out-of-Network
Preventative Care	Fully covered	$190 copay
Primary Care	$15-$100 copay	$300 copay
Specialist Services	$15-$100 copay	$300 copay
Diagnostic Care	Routine: Fully covered, Non-Routine: $20 - $1,400 copay	Routine: Fully covered, Non-Routine: Up to $4,200 copay
Mental Health - Inpatient	$2,750 copay	$8,250 copay
Mental Health- Outpatient	Home/Office: $15 copay; Outpatient Facility: $150 copay	Home/Office: $190 copay; Outpatient Facility: $450 copay
Urgent Care	$80 copay	$240 copay
Emergency Room	$750 copay	$750 copay

Preventative Care

In-Network: Fully covered
Out-of-Network: $190 copay

Primary Care

In-Network: $15-$100 copay
Out-of-Network: $300 copay

Specialist Services

In-Network: $15-$100 copay
Out-of-Network: $300 copay

Diagnostic Care

In-Network: Routine: Fully covered, Non-Routine: $20 - $1,400 copay
Out-of-Network: Routine: Fully covered, Non-Routine: Up to $4,200 copay

Mental Health - Inpatient

In-Network: $2,750 copay
Out-of-Network: $8,250 copay

Mental Health- Outpatient

In-Network: Home/Office: $15 copay; Outpatient Facility: $150 copay
Out-of-Network: Home/Office: $190 copay; Outpatient Facility: $450 copay

Urgent Care

In-Network: $80 copay
Out-of-Network: $240 copay

Emergency Room

In-Network: $750 copay
Out-of-Network: $750 copay

*After deductible

Pharmacy Benefits

Tier	Cost
Retail RX - Generic	$10 copay
Retail RX - Preferred	$90 copay
Retail RX - Non-Preferred	$120 copay
Retail RX - Specialty Drugs	$330-$400 copay
Mail Order RX - Generic	$25 copay
Mail Order RX - Preferred	$225 copay
Mail Order RX - Non-Preferred	$300 copay
Mail Order RX - Specialty Drugs	N/A

Retail RX - Generic

Cost: $10 copay

Retail RX - Preferred

Cost: $90 copay

Retail RX - Non-Preferred

Cost: $120 copay

Retail RX - Specialty Drugs

Cost: $330-$400 copay

Mail Order RX - Generic

Cost: $25 copay

Mail Order RX - Preferred

Cost: $225 copay

Mail Order RX - Non-Preferred

Cost: $300 copay

Mail Order RX - Specialty Drugs

Cost: N/A

*After deductible

Plan Notes

The Surest plan simplifies the healthcare system outside of the exam room.
Search for conditions or providers in the Surest app, on benefits.surest.com, or by calling the Surest Member Services.