| Plan Basics |
| Plan Year Deductible | None |
| Members Coinsurance | None |
Plan Year Out-of-Pocket Maximum per Person
Including deductible | Co-payments |
| Plan Year Maximum Benefit | $50,000 |
| Lifetime Maximum Benefit | $250,000 |
Hospital Benefits |
Inpatient Hospital Services
(UTMB Only) | $200 co-payment per day
Maximum FIVE days covered per plan year |
Outpatient Hospital Services
(UTMB Only)
Services include: Outpatient or Same Day Surgery
and 23 hour Observations | $75 co-payment
Maximum TWO services covered per plan year |
Ancillary Services
(UTMB Only)
Radiology and Diagnostic Testing | $75 co-payment for the following diagnostic tests:
Maximum ONE screening covered per plan year:
Mammogram*, Colonoscopy or Osteoporosis
And
$75 co-payment for the following diagnostic scans:
Maximum ONE major image covered per plan year:
MRI, CT or PET scan |
Physical Therapy / Occupational Therapy
Requested and approved by PCP | $30 co-payment
Maximum SIX visits covered per plan year |
Emergency Room Visits
(UTMB Galveston or UTMB Victory Lakes only) | $75 co-payment
Maximum TWO visits covered per plan year |
Physician Benefit |
Inpatient Hospital Care
(UTMB Only) | Maximum FIVE days covered per plan year |
Outpatient Hospital Care
(UTMB Only) | Maximum TWO visits covered per plan year |
Doctor Office Visits and Urgent Care Visits
Includes primary care, specialty care, outpatient mental health care, routine lab and first maternity visit | $15 PCP & Urgent Care co-payment
$30 Specialist co-payment
Maximum TWENTY visits covered per plan year |
Radiology and Pathology
Routine imaging as medically necessary and requested by PCP/Specialist. Does not include MRI, CT or PET scans or other imaging as determined by the Plan | Covered |
Pharmacy Benefits |
| Deductible | None |
| Member Coinsurance | None |
| Co-Payments | $4 generic program through Wal-Mart, HEB, etc.
$25 co-payment for generic
$50 co-payment for non-generic |
| Annual Pharmacy Maximum | $1,200 maximum per plan year |