PPO Summary

This is a summary. Please log into your UMR account to see the plan description.

Plan Summary Effective 2017-18
Service In-Network Benefits
Member Pays
Out-of-Network Benefits
Member Pays
Calendar Year Deductible* $350 individual
$700 family
$5,000 single†
$10,000 family†
Medical Out-of-Pocket Maximum*
(deductibles and coinsurance)
$2,100 individual
$4,200 family
$6,350 single†
$12,700 family†
Plan Out-of-Pocket
(deductible, coinsurance, and copayments)
$6,350 individual
$12,700 family
$6,350 single†
$12,700 family†
Preventive Care
(wellness exams, cancer screenings, immunizations)
0% 50% after deductible†
Office Visits
(primary care physician)
$25 copayment 50% after deductible†
Behavioral Health $25 copayment 50% after deductible†
Specialist/Allergist $35 copayment 50% after deductible†
Physician Services
(outside of office)
20% after deductible
0% after medical out-of-pocket
50% after deductible†
Diagnostic X-Rays and Lab Work 10% or 20% after deductible**
0% after medical out-of-pocket
50% after deductible†
Free-Standing Laboratory 0% 50% after deductible†
Advanced Imaging 
(such as MRI, CAT, PET)
10% or 20% after deductible**
0% after medical out-of-pocket
50% after deductible†
Free-Standing Advanced Imaging 0% 50% after deductible†
Hospital Emergency Room Services $100 copayment
(waived if admitted)
50% after deductible†
Urgent Care Facility $35 copayment 50% after deductible†
Speech Therapy
(limit 30 visits per year)
$35 copayment 50% after deductible†
Physical and Occupational Therapy
(limit 60 visits per year)
$35 copayment 50% after deductible†
Acupuncture
(limit 20 visits per year)
$35 copayment 50% after deductible†
Chiropractic Services
(limit 20 visits per year)
$35 copayment 50% after deductible†
Pharmacy Tiered at $10, $35, $60, $100 copays.

* Each covered member only needs to satisfy the individual deductible or out-of-pocket maximum before receiving in-network benefits.

** Coinsurance percentage based on network Hospital Tiering

† Out-of-network providers may balance bill you for charges in excess of the maximum allowable fee.You will be responsible for charges in excess of the maximum allowable fee in addition to any applicable deductible, coinsurance or co-payment. Additionally, any amount you pay the provider in excess of the maximum allowable fee will not apply to your deductible or out-of-pocket maximum.

Physician, other health care professionals and non-facility providers are responsible for Advance authorization.