Tiered PPO Plan

Insurance

The Kansas City tiered feature for the PPO Plan (called the "PPO Plan with Tiered Feature" here) is available to faculty and staff who work for the UMKC business unit. Employees at other business units should refer to the PPO Plan. Retirees and their dependents are not eligible for this plan; instead, they have access to the Retiree Health PPO Plan.

Discounts

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

  2021 PPO Plan with Tiered Feature  

Premiums

Monthly employee premium cost for active employees:

• Self only: $176
• Self and spouse: $417
• Self and child(ren): $374
• Self, spouse and child(ren): $632

Deductibles

The PPO Plan with Tiered Feature 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 PPO Plan and Custom Network Plan than the Healthy Savings Plan. Visit the glossary for details.

Out-of-pocket limits

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

• Medical out-of-pocket limit:
  • In-network: $3,500/self*; $7,000/family*
  • Out-of-network**: $10,500 or more/self; $21,000 or more/family*
• Rx out-of-pocket limit:
  • $5,050/self*; $10,100/family*

* Considerations for “self” and “family” are different for the PPO Plan and Custom Network Plan than for 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.

Prescription drug costs

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.

• Prescription drug: Retail:
  • In-network: Greater of (after Rx deductible):
    • Formulary generic: $7 copay or 20% coinsurance
    • Formulary brand: $15 copay or 25% coinsurance
    • Non-formulary brand: $30 copay or 50% coinsurance
  • Out-of-network**: $30 copay or 50% network costs or more after deductible**
• Prescription drug: Mail:
  • In-network: Greater of:
    • Formulary generic: $15 or 20% coinsurance
    • Formulary brand: $30 or 25% coinsurance
    • Non-formulary brand: $60 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.

Network providers

The PPO plan with Tiered Feature makes two tiers of providers within the Choice Plus network available:

1. 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 your costs for services.
2. 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 a designation.

You may choose to visit either in-network or out-of-network doctors 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.

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).

Consider a Flexible Spending Account

If you enroll in the 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.

  2020 PPO Plan with Tiered Feature  

Premiums

Deductibles

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

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

Out-of-pocket limits

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

* Considerations for “self” and “family” are different for the PPO Plan and Custom Network Plan than for 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.

Prescription drug costs

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.

* 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.

Network providers

The PPO plan with Tiered Feature makes two tiers of providers within the Choice Plus network available:

1. 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 your costs for services.
2. 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 a designation.

You may choose to visit either in-network or out-of-network doctors 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.

Preventive care

Many health plans include preventive care services, such as various screenings, vaccinations and well-woman visits, at no out-of pocket cost. Learn more about UHC's preventive care guidelines (exit to UHC website).

Consider a Flexible Spending Account

If you enroll in the 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.

* In the event of a difference between this webpage and the plan document or summary plan description, the plan document and plan description prevail.