Medical Benefits
IHTSC has two Medical Plans to choose from: H.S.A. Plan or PPO Plan
Network is United Health Care Options PPO
Plan Year (01/01/2018-12/31/2018)
H.S.A. Plan
H.S.A. Plan IN-NETWORK/OUT-OF-NETWORK
Annual Deductible Per Calendar Year:
Medical and Pharmacy Expenses are Subject to the same deductible.
Indiv. Deductible………………………….. $3000 / $6000
Family Deductible………………………… $6000 / $12,000
Coinsurance Amt:
(Paid by plan after satisfaction of Deductible) ……………………….100% / 70%
Annual Total Out-of-Pocket Maximum:
Medical and Pharmacy Expenses are Subject to the same Out-of-Pocket maximum.
Individual…………..…………………………. $3000 / $12,000
Family………………..………………………… $6000 / $24,000
Primary Care office visit
(Paid by plan after deductible) ……………. 100% / 70%
Specialist office visit
(Paid by plan after deductible) ……………. 100% /70%
Preventive / Routine Care Benefits ……………………………………… 100% / 70%
(Deductible Waived)
• See Medical Schedule of Benefits for details
Hospital Services:
Pre-Admission Testing
(Paid by plan after deductible)……………………………………………………… 100% / 70%
Impatient Services / Inpatient Physician charges;
Room & Board Subject to the Payment
of Semi-Private Room Rate or Negotiated Room Rate
(Paid by plan after deductible) ……………………………………………… 100% / 70%
Outpatient Services / Outpatient Physician Charges
(Paid by plan after deductible)……………………………………………... 100% / 70%
Outpatient Imaging Charges
(Paid by plan after deductible) …………………………………………….. 100% / 70%
Outpatient Lab & X-Ray Charges
(Paid by plan after deductible) ……………………………………………. 100% / 70%
Outpatient Surgery / Surgeon Charges
(Paid by plan after deductible) …………………………………………….. 100% / 70%
Emergency Services / Treatment:
Urgent Care
(Paid by plan after deductible) ……………………………………………… 100% / 70%
Emergency Room / Emergency Physicians
(Paid by plan after deductible) …………………………………………….. 100% / 100%
Mental Health, Substance Use Disorder, and Chemical Dependency:
Impatient Services / Physician Charges
(Paid by plan after deductible) ……………………………….. 100% /70%
Residential Treatment
(Paid by plan after deductible) ……………………………….. 100% /70%
Outpatient or Partial Hospitalization Services
& Physician charges
(Paid by plan after deductible) ………………………………… 100% /70%
Office Visit
(Paid by plan after deductible) ………………………………… 100% /70%
Therapy Services:
(Paid by plan after deductible) ………………………………… 100% /70%
• Medical Necessity will be reviewed after 25 visits.
Hospices Care Benefits:
(Paid by plan after deductible) ………………………………… 100% /70%
Prescription Benefits
Annual Pharmacy Deductible Per Calendar Year:
Medical and Pharmacy Expenses are subject to the same Medical Deductible.
Per Person ………………………………….. $3000
Per Family …………………………………… $6000
Annual Pharmacy Out-of-Pocket Maximum Per Calendar Year:
Medical and Pharmacy Expenses are subject to the same Medical Out-of-Pocket Maximum.
Per Person ………………………………….. $3000
Per Family …………………………………… $6000
Prescriptions (retail – 34 day supply)………………………. Deductible then 100%
• Must be participating retail pharmacy
Prescriptions (mail order – 90 day supply) ……………… Deductible then 100%
Specialty Drugs (up to 34 Day Supply) …………………….. Deductible then 100%
• Specialty Drugs must be purchased at a Specialty Pharmacy
Pharmacy Provider: Optum Rx
Check provider online at www.UMR.com and navigate to the myPharmacyCenter or call 877-559-2955
H.S.A. Plan
Standard Premium
Employee Only $61.60
Employee & Spouse $167.48
Employee & Children $190.01
Family $307.53
Non-Nicotine Discounted Premium
Employee Only $46.39
Employee & Spouse $135.45
Employee & Children $151.79
Family $220.90
H.S.A. Forms Download
PPO Plan
PPO Plan IN-NETWORK/OUT-OF-NETWORK
Annual Deductible Per Calendar Year:
Medical & Specialty Pharmacy Expenses are subject to the same Deductible
Indiv. Deductible………………………….. $1800 / $3600
Family Deductible………………………… $3600 / $7200
Coinsurance Amt:
(Paid by Plan after satisfaction of Deductible)………………………………….. 80% / 50%
Annual Total Out-of-Pocket Maximum Per Calendar Year:
Medical & Specialty Pharmacy Expenses are subject to the same Out-of-Pocket Maximum
Indiv. Out of Pocket Max……………… $2500 / $5000
Family Out of Pocket Max……………. $5000 / $10,000
Primary Care & Specialist office visit
Copay Per Visit…………………………………………… $40
Paid by Plan After Deductible……………………. 100% (Deductible Waived) / 50%
Physician Office Services
Paid by Plan After Deductible …………………………………. 80% / 50%
Preventive / Routine Care Benefits………………………………… 100% / 50% (Deductible Waived)
• See Medical Schedule of Benefits for Details
Hospital Services
Pre-Admission Testing
(Paid by plan after deductible) ……………………………………………. 80% / 50%
Impatient Services / Inpatient Physician charges;
Room & Board Subject to the Payment
of Semi-Private Room Rate or Negotiated Room Rate
(Paid by plan after deductible) ………………………………………………. 80% / 50%
Outpatient services / Outpatient Physician Charges:
(Paid by plan after deductible) …………………………………………….. 80% / 50%
Outpatient Lab & X-Ray Charges:
(Paid by plan after deductible) ……………………………………………… 80% / 50%
Outpatient Surgery / Surgeon Charges:
(Paid by plan after deductible) ……………………………………………… 80% / 50%
Emergency Services / Treatment:
Urgent Care
(Paid by plan after deductible) ………………………………………………. 80% / 50%
Emergency Room visit
(Paid by plan after deductible) ………………………………………………. 80% / 50%
Mental Health, Substance Use Disorder & Chemical Dependency Benefits:
Impatient Services / Physician Charges:
(Paid by plan after deductible) ………………………………. 80% / 50%
Residential Treatment
(Paid by plan after deductible) ……………………………….. 80% / 50%
Out Patient or Partial Hospitalization Services
& Physician Charges
(Paid by plan after deductible) ………………………………… 80% / 50%
Office Visit:
Copay Per visit………………………………………………………… $40 Copay,
(Paid by plan after deductible) ………………………………. 80% (Deductible Waived) / 50%
Therapy Services:
Paid by Plan after Deductible………………………………… 80% / 50%
Hospices Care Benefits:
Paid by Plan After Deductible………………………………… 80% / 50%
Prescription Benefits
Medical & Specialty Pharmacy Expenses are subject to the same Medical Deductible
Annual Deductible Per Calendar Year:
Per Person ………………………………………………… $1800
Per Family ……………………………………………….... $3600
Applies to: Specialty
Annual Out-of-Pocket Maximum per Calendar Year:
Medical & Specialty Pharmacy Expenses are subject to the same Medical Out-of-Pocket Maximum
Per Person ………………………………………………… $2500
Per Family ……………………………………………….... $5000
Applies to: Specialty
Once the Annual Out-of-Pocket Maximum is met, then the covered person pays zero for covered Specialty Prescription Medication.
By Participating Retail Pharmacy
Covered Person’s Co-pay Amount……………… For up to a 34-Day Supply:
Generic Drugs (Tier 1) ……………………………….. $30
Brand-Name Drugs (Tier 2) ……………………….. $55
By Participating Mail Order Pharmacy
Covered Perosn’s Co-pay Amount ……………… For up to a 90-Day Supply:
Generic Drugs (Tier) 1 ……………………………… $55
Brand-Name Drugs (Tier) 2 ……………………… $110
After 2 Retail Fills, Mail Service is Required
Specialty Drugs
Covered Person’s Co-pay Amount ……………… For up to a 34-Day Supply:
Generic Drugs (Tier) 1 ……………………………… 20%
Brand-Name Drugs (Tier) 2 ……………………… 20%
Specialty Drugs Must be Purchased at a Specialty Pharmacy Vendor
Pharmacy Provider: Optum Rx
Check provider online at www.UMR.com and navigate to the myPharmacyCenter or call 877-559-2955
Standard Premium
Employee Only $123.22
Employee & Spouse $273.16
Employee & Children $268.34
Family $389.68
Non-Nicotine Discounted Premium
Employee Only $92.78
Employee & Spouse $215.95
Employee & Children $211.58
Family $282.25
PPO Forms Download
- Flexible Spending Account Employee Guide
- Flexible Spending Account Employee Handout
- Reimbursement Form
- FSA Election Form