Page 5 - 2018-19 US Tool Benefit Guide
P. 5
Plan Details
UMR
Premier Plan Basic Plan
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Embedded Embedded Embedded Embedded
Individual $750 $1,250 $1,500 $3,000
Family $1,750 $2,750 $3,750 $7,500
Out-of-Pocket Maximum
Individual $1,750 $3,250 $5,000 $10,000
Family $3,500 $6,500 $12,500 $25,000
Physician Ofice Visits
Primary Care $25 copay 60% after deductible $25 copay 60% after deductible
Specialist $40 copay 60% after deductible $40 copay 60% after deductible
Urgent Care $50 copay 60% after deductible $50 copay 60% after deductible
Teladoc $25 copay 60% after deductible $25 copay 60% after deductible
Wellness/Preventive
Routine Physical Exams
Routine Immunizations
Well Childcare Covered at 100% 60% after deductible Covered at 100% 60% after deductible
Annual Well Women
Mammograms
Hospital Services
Inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Emergency Room $250 copay $250 copay $250 copay $250 copay
Labs and Imaging
Diagnostic Test (x-ray, 100% 60% after deductible 100% 60% after deductible
blood work)
Imaging (CT/PET scans, 80% after deductible 60% after deductible 80% after deductible 60% after deductible
MRIs)
Mental Health and Substance Abuse
Inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient $25 copay 60% after deductible $25 copay 60% after deductible
* The ofice visit copay applies when the physician bills for an ofice visit. Labs and non-major diagnostics are covered at 100%. All other services
are subject to ded/coinsurance. Examples of these other services include but are not limited to major diagnostics (CT, PET, MRI scans, etc.),
nuclear medicine, therapeutic scopic procedures, surgery, therapeutic treatments, allergy injections, etc.
** Exceptions: major diagnostics (CT, PET, MRI nuclear medicine, etc.) which are deductible/coinsurance
For out-of-network coverage details, please refer to your summary plan description (SPD) or an oficial plan
document.
US Tool Group 5
UMR
Premier Plan Basic Plan
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Embedded Embedded Embedded Embedded
Individual $750 $1,250 $1,500 $3,000
Family $1,750 $2,750 $3,750 $7,500
Out-of-Pocket Maximum
Individual $1,750 $3,250 $5,000 $10,000
Family $3,500 $6,500 $12,500 $25,000
Physician Ofice Visits
Primary Care $25 copay 60% after deductible $25 copay 60% after deductible
Specialist $40 copay 60% after deductible $40 copay 60% after deductible
Urgent Care $50 copay 60% after deductible $50 copay 60% after deductible
Teladoc $25 copay 60% after deductible $25 copay 60% after deductible
Wellness/Preventive
Routine Physical Exams
Routine Immunizations
Well Childcare Covered at 100% 60% after deductible Covered at 100% 60% after deductible
Annual Well Women
Mammograms
Hospital Services
Inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Emergency Room $250 copay $250 copay $250 copay $250 copay
Labs and Imaging
Diagnostic Test (x-ray, 100% 60% after deductible 100% 60% after deductible
blood work)
Imaging (CT/PET scans, 80% after deductible 60% after deductible 80% after deductible 60% after deductible
MRIs)
Mental Health and Substance Abuse
Inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient $25 copay 60% after deductible $25 copay 60% after deductible
* The ofice visit copay applies when the physician bills for an ofice visit. Labs and non-major diagnostics are covered at 100%. All other services
are subject to ded/coinsurance. Examples of these other services include but are not limited to major diagnostics (CT, PET, MRI scans, etc.),
nuclear medicine, therapeutic scopic procedures, surgery, therapeutic treatments, allergy injections, etc.
** Exceptions: major diagnostics (CT, PET, MRI nuclear medicine, etc.) which are deductible/coinsurance
For out-of-network coverage details, please refer to your summary plan description (SPD) or an oficial plan
document.
US Tool Group 5
