PPO Plan with Tiered Feature (Tiered PPO Plan)

• There are separate deductibles for in-network services and retail prescription drugs.
• Once you meet your annual out-of-pocket limit, the plan pays 100% of expenses (including coinsurance and copayments) for the remainder of the calendar year.
• You can enroll in two types of Flexible Spending Accounts (FSA): Health Care FSA and Dependent Care FSA. These accounts help you pay for medical or child care using pre- tax dollars. Eligible expenses differ between the types.
• For those in the Columbia area, 90-day fills/refills are available at Mizzou pharmacies at the same cost as mail-order. Participants may fill specialty medications through a Mizzou Specialty Pharmacy or Accredo.

All active benefit-eligible faculty and staff have access to a type of PPO Plan, but may have access to the additional tiered feature depending on where they live and/or work. If you are a benefit-eligible faculty or staff member with a home or business address in an eligible county around Kansas City or Rolla, the Tiered PPO Plan is available to you. Counties eligible are as follows:

Access to the tiered feature is determined by address. If you do not live or work in one of the counties eligible for the tiered feature, then you will have access to the base PPO Plan.

Eligibility for both PPO Plan versions

Most faculty and staff have one version of the PPO Plan available to them (either with or without Tiered Feature). However, a small group have home and business addresses such that both PPO Plan options will show up in myHR as available when completing enrollment. In this case, you will have the option to enroll in either of the two insurance plans, so take extra caution to ensure that you select the version that is best for you.

Like its name suggests, PPO Plan with Tiered Feature participants have access to two tiers of providers within UHC’s Choice Plus Network.

• Tier 1: Includes premium care physicians; providers rated as having two hearts (♥♥) by UHC because of their high-quality, cost-effective care. Utilizing this tier may help you lower costs for services.
• Tier 2: Includes certain types of specialists; providers rated as having one heart (♥) by UHC; and providers who are unrated or do not meet the criteria for designation.

Those eligible for the PPO Plan with Tiered Feature enjoy savings when they use Tier 1 providers but will always have access to a broad network through Tier 2. Providers can be considered Tier 2 solely due to their specialty, or because they don’t meet the criteria for the designation and therefore are unrated. These providers have still been determined to offer quality care. 

Additionally, they save when using non-hospital-affiliated, free-standing facilities, ambulatory surgical centers or physician offices (designated network) instead of outpatient hospital facilities (network) for services such as labs, x-rays, scans and outpatient surgery.

Monthly employee premium cost* for active employees:

• Self only: $196
• Self and spouse: $479
• Self and child(ren): $455
• Self, spouse and child(ren): $769

*Premiums for faculty on a nine-month contract paid over nine months are different. For more information, visit the Premiums for 9-month faculty paid over 9 months webpage.

What you pay for covered services varies based on whether the provider is in-network or out-of-network:

**Refer to the Summary Plan Description (SPD) for additional details on allowable and eligible expenses when using an out-of- network provider.

^^Participants may save when using non-hospital-affiliated, free-standing facilities, ambulatory surgical centers or physician offices (designated network) instead of outpatient hospital facilities (network) for services such as labs, x-rays, scans and outpatient surgery.

• Prescription drug: Retail Non-Maintenance:
  • In-network: Greater of (after Rx deductible):
    • Formulary generic: $10 copay or 20% coinsurance
    • Formulary brand: $30 copay or 25% coinsurance
    • Non-formulary brand: $50 copay or 50% coinsurance
  • Out-of-network**: $30 copay or 50% network costs or more after deductible**
• Prescription drug: Retail Maintenance:
  • In-network: Greater of (after Rx deductible):
    • Formulary generic: $15 copay or 25% coinsurance
    • Formulary brand: $40 copay or 30% coinsurance
    • Non-formulary brand: $60 copay or 55% coinsurance
  • Out-of-network**: $30 copay or 50% network costs or more after deductible**
• Prescription drug: Mail:
  • In-network: Greater of:
    • Formulary generic: $20 or 20% coinsurance
    • Formulary brand: $60 or 25% coinsurance
    • Non-formulary brand: $100 or 50% coinsurance
  • Out-of-network**: $30 copay or 50% network costs or more after deductible**

* 90-day fill/refill at Mizzou pharmacies at same cost as mail-order.
** Member will pay difference between the non-participating and participating pharmacy charge.

The Tiered PPO Plan has two annual deductibles: one for medical and a second for prescription drug costs.

• Medical deductible:
  • In-network: $500/self*; $1,500/family
  • Out-of-network: $1,000/self*; $3,000/family*
• Rx deductible:
  • Retail: $75/person
  • Mail-order: $0/person

* Considerations for “self” and “family” are different for the Custom Network Plan and PPO Plan than the Healthy Savings Plan. Visit the glossary for details.

The Tiered PPO Plan has two annual out-of-pocket limits: one for medical and a second for prescription drug costs.

• Medical out-of-pocket limit:
  • In-network: $3,750/self*; $7,500/family*
  • Out-of-network**: $11,250 or more/self; $22,500 or more/family*
• Rx out-of-pocket limit:
  • $5,450/self*; $10,900/family*

* Considerations for “self” and “family” are different for the Custom Network Plan and PPO Plan than the Healthy Savings Plan. Visit the glossary for details.
**Please refer to the Summary Plan Description (SPD) for additional details on allowable/eligible expenses when using an out-of-network provider.

If you enroll in the Tiered PPO Plan, you may also want to consider enrolling in a Health Care Flexible Spending Account (FSA), an account that allows you to set aside pre-tax dollars to pay for out-of-pocket medical expenses. Visit the Understanding your flexible spending account webpage to learn more.

To estimate prescription costs, visit Express Script's prescription cost estimator tool (exit UM System site) for UM System medical plans. Select the plan year and health plan you wish to review; then, select "price a medicine" and type in the medicine's name. You will be prompted to select the strength, form, quantity and frequency for the prescription to estimate the cost covered by the plan and the cost to you.

You may choose to visit either in-network or out-of-network physicians and other providers. Your costs will be lower, however, when you select in-network providers. Provider directories may be accessed on the plan contacts webpage.

Virtual visits are also available to you. Virtual visits let you see and talk to a doctor from your mobile device or computer without an appointment, any time. Visit the virtual visits webpage to learn more.

Making an informed decision about your healthcare needs can save you time and money, but when you are ill or injured, assessing your condition and choosing the best place to go for treatment isn’t easy. You have four care options, but each is unique in the services it provides.

Primary care physician

Visit your primary care physician when you have a non-life threatening condition during regular hours of work week, or if you don’t need immediate attention. It’s always best to see your primary care physician, since they know you and your health history. 

• Examples include: Persistent cough; sore throat or rash; minor injuries or aches

Convenience care clinic

When you experience symptoms where you would normally see a primary care physician, but it’s after hours or on a weekend, a convenience care clinic can be a good option. Convenience care clinics are typically available in local retail or drug stores and usually have extended hours on weekdays and weekends.  

• Examples include: Persistent cough; sore throat or rash; minor injuries or aches

Urgent care clinic

Urgent care clinics are an appropriate choice when you have an unexpected illness or injury that requires immediate attention but is not necessarily life-threatening. These clinics offer many resources to treat a wound or injury and will often do so immediately. 

• Examples include: A cut that may need stitches; a sprained ankle

Emergency room

Seek an emergency room when an illness or injury is very serious or life-threatening. In most cases, you will know the condition is serious, sudden and/or requires immediate attention. If you are unable to get to an emergency room, call 9-1-1 for assistance. 

• Examples include: Broken bones with deformed appearances; head trauma; drug or alcohol overdoses; severe cuts or burns. 

Preventive Care

Many health plans include preventive care services, such as various screenings, vaccinations and well-woman visits, at no out-of pocket cost. Read about women's preventive healthcare or learn more about UHC's preventive care guidelines (exit UM System site).

Special Health Topics

Consult the following webpages for additional information on special health topics:

• Autism
• Behavioral Health
• Diabetes
• Hearing

Visit the health and wellness tools and discounts webpage to maximize your convenience and savings.