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PPO Plan with Tiered Feature (Tiered PPO Plan)

The PPO Plan with Tiered Feature (also called Tiered PPO Plan) is available to benefit-eligible faculty and staff who live or work in an eligible county in and around the Kansas City and Rolla geographic areas. Employees who live and work outside of those counties have access to the base PPO Plan, which follows the same plan structure but does not utilize Tiered Feature. Retirees and their dependents are not eligible for this plan; instead, they have access to the Retiree Health PPO Plan.

Jump to: 2022 Tiered PPO Plan | 2021 Tiered PPO Plan

  2022 PPO Plan with Tiered Feature  

Iconographic illustration of a medical cadeuceusAbout the Plan

The PPO Plan with Tiered Feature is available to benefit-eligible employees who live or work in one of the counties that makes you eligible. Like its name suggests, it is a PPO-structured medical insurance plan with a broad network of providers. You pay deductibles for medical expenses and prescription drugs even if you use in-network services, though certain providers have lower costs depending on their tier level. This means, for most covered expenses, you’ll pay for expenses until you reach the annual deductible.

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💠 Plan Features

  • 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.
 

Eligibility

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:

  • Kansas City: There are eligible counties in both Missouri and Kansas.
    • Missouri counties: Cass, Clay, Jackson, Johnson, Lafayette, Platte and Ray.
    • Kansas counties: Johnson and Wyandotte.
  • Rolla: There are eligible counties in mid-Missouri.
    • Missouri counties: Crawford, Dent, Gasconade, Maries, Phelps, Pulaski and Texas.
  • See the Tiered PPO coverage map (PDF, 109KB).

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.

 

💕 Provider Tiers

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.

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.

 

Costs

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💲 Premiums

Monthly employee premium cost for active employees:

  • Self only: $176
  • Self and spouse: $426
  • Self and child(ren): $391
  • Self, spouse and child(ren): $661
 

🩺 Covered Services

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

In-Network Services
  • Preventive Care: $0
  • Primary Care:
    • Tier 1 (♥♥): $15 copay/visit;
    • Tier 2 (♥): $25 copay/visit
  • Specialist Care:
    • Tier 1 (♥♥): $35 copay/visit;
    • Tier 2 (♥): $40 copay/visit
  • Urgent Care: $50 copay/visit
  • Lab and X-ray^^:
    • Designated network: 10% coinsurance after deductible
    • Network: 20% coinsurance after deductible
  • Outpatient Care^^:
    • Designated network: 10% coinsurance after deductible
    • Network: 20% coinsurance after deductible
  • Inpatient Care: (includes maternity delivery)
    • Designated network: 10% coinsurance after deductible
    • Network: 20% coinsurance after deductible
  • Durable medical equipment: 10% after deductible
  • Emergency room: $250 copay/visit after deductible
  • Ambulance: $200 copay/occurrence after deductible
Out-of-Network Services**
  • Preventive Care: 40% or more after deductible
  • Primary Care: 40% or more after deductible
  • Specialist Care: 40% or more after deductible
  • Urgent Care: 40% or more after deductible
  • Lab and X-ray: 40% or more after deductible
  • Outpatient Care: 40% or more after deductible
    • Includes maternity delivery
  • Durable medical equipment: 40% or more after deductible
  • Emergency room: $250 copay/visit or more after deductible
  • Ambulance: $200 copay/occurrence or more after deductible

 

**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 Drugs

  • 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.

 

➖ Deductible

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.

 

🧾 Out-of-Pocket Limit

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: $3,500/self*; $7,000/family*
    • Out-of-network**: $10,500 or more/self; $21,000 or more/family*
  • Rx out-of-pocket limit:
    • $5,200/self*; $10,400/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.

 

For a printable version, download the Plan Information and Comparison handout (375KB, PDF), which features a comparison chart and premium rates for the available insurance plans.


Making the Most of Your Plan

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💳 Consider a Flexible Spending Account

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.

 

📋 Rx Cost Estimator

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.

 

🏥 Network Providers

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

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 and Special Health Topics

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:

 

🏷 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.

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

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Reviewed 2021-09-24