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Medical

High-Deductible Health Plan – $3,500
  In-Network Out-of-Network
Plan Deductible $3,500 individual / $7,000 family $7,000 individual / $14,000 family
Annual Out-of-Pocket Maximum $4,500 individual / $9,000 family $14,000 individual / $28,000 family
Coinsurance 100% 50%
Primary Care Visits $25 Copay after Deductible 50% after Deductible
Preventive Care $0 Copay 50% after Deductible
Specialists Visits $75 Copay after Deductible 50% after Deductible
Inpatient Visit 0% after Deductible 50% after Deductible
Outpatient Services 0% after Deductible 50% after Deductible
Emergency Room $300 Copay after Deductible $300 Copay after Deductible
Urgent Care $50 Copay after Deductible 50% after Deductible
Rx Retail (30-Day Fill) In-Network Out-of-Network
Generic $10 Copay after Deductible Not Covered
Preferred Brand $35 Copay after Deductible Not Covered
Non-Preferred Brand $70 Copay after Deductible Not Covered
Specialty $150 Copay after Deductible Not Covered
Rx Mail Order (90-Day Fill) In-Network Out-of-Network
Generic $25 Copay after Deductible Not Covered
Preferred Brand $87.50 Copay after Deductible Not Covered
Non-Preferred Brand $175 Copay after Deductible Not Covered
Coverage Level Rates per Pay (52 pays)
Employee $43.13
Employee + Spouse $83.50
Employee + Child(ren) $67.35
Family $116.60
Medical
Medical

www.myuhc.com
Benefits.Surest.com
866-683-6440

Resources

Plan Differences

UHC HDHP/HSA Plans Only

HDHP 3500 SBC

HDHP 5000 SBC

Surest Only

Surest Only – 2nd MD

Surest Only – Doctor onDemand

Surest Only – How to Find Care

Surest Only – One Pass Flyer

Surest Only – Real Appeal Flyer

Surest Only – Register Member Account

Surest Only – Talkspace Go Flyer

Surest SBC

High-Deductible Health Plan – $5,000
  In-Network Out-of-Network
Plan Deductible $5,000 individual / $10,000 family $10,000 individual / $20,000 family
Annual Out-of-Pocket Maximum $6,900 individual / $13,800 family $20,000 individual / $40,000 family
Coinsurance 100% 50%
Primary Care Visits $25 Copay after Deductible 50% after Deductible
Preventive Care $0 Copay 50% after Deductible
Specialists Visits $75 Copay after Deductible 50% after Deductible
Inpatient Visit 0% after Deductible 50% after Deductible
Outpatient Services 0% after Deductible 50% after Deductible
Emergency Room $300 Copay after Deductible $300 Copay after Deductible
Urgent Care $50 Copay after Deductible 50% after Deductible
Rx Retail (30-Day Fill) In-Network Out-of-Network
Generic $10 Copay after Deductible Not Covered
Preferred Brand $35 Copay after Deductible Not Covered
Non-Preferred Brand $70 Copay after Deductible Not Covered
Specialty $150 Copay after Deductible Not Covered
Rx Mail Order (90-Day Fill) In-Network Out-of-Network
Generic $25 Copay after Deductible Not Covered
Preferred Brand $87.50 Copay after Deductible Not Covered
Non-Preferred Brand $175 Copay after Deductible Not Covered
Coverage Level Rates per Pay (52 pays)
Employee $34.84
Employee + Spouse $66.92
Employee + Child(ren) $54.09
Family $93.23
Surest Plan – No Deductible
  In-Network Out-of-Network
Plan Deductible $0 individual / $0 family $0 individua l/ $0 family
Annual Out-of-Pocket Maximum $5,000 individual / $10,000 family $10,000 individual / $20,000 family
Coinsurance 0% 0%
Primary Care Visits $20 – $105 Copay $215 Copay
Preventive Care $0 Copay $160 Copay
Specialists Visits $20 – $105 Copay $215 Copay
Inpatient Visit $200 – $3,000 Copay Up to $9,000 Copay
Outpatient Services $35 – $3,000 Copay Up to $9,000 Copay
Emergency Room $600 Copay $600 Copay
Urgent Care $60 Copay $180 Copay
Rx Retail (30-Day Fill) In-Network Out-of-Network
Generic $20 $20
Preferred Brand $90 $90
Non-Preferred Brand $150 $150
Specialty $20 / $200 / $500 $20 / $200 / $500
Rx Mail Order (90-Day Fill) In-Network Out-of-Network
Generic $50 $50
Preferred Brand $225 $225
Non-Preferred Brand $375 $375

For Non-Members who want to view the Surest website to compare costs, look up providers and experience how the Surest plan works, please visit this link: Surest Plan Overview.

Coverage Level Rates per Pay (52 pays)
Employee $55.64
Employee + Spouse $108.53
Employee + Child(ren) $87.37
Family $151.89
The STG Family of Companies
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