Medical Plans At A Glance
Base Plan (UMR)
Premium Option 1 (UMR)
Premium Option 2 (Surest) UHC Choice Plus Network
UHC Choice Plus Network
UHC Choice Plus Network
In-Network
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
Deductible Individual | Family Co-Insurance Plan | Member
$4,500 | $9,000 $9,000 | $18,000 $1,500 | $3,000 $3,000 | $6,000
$0 | $0
$0 | $0
0%
70% | 30%
50% | 50%
70% | 30%
50% | 50%
0%
Max Out-of-Pocket (Includes Deductible, Coinsurance, and Med & Rx Copays)
$6,150 | $12,300 $12,300 | $24,600 $4,500 | $9,000 $9,000 | $18,000 $6,000 | $12,000 $12,000 | $24,000
Benefits
Preventive Care
Plan pays 100% Not Covered
Plan pays 100% Not Covered
Plan pays 100%
$150
$30 Copay | $50 Copay
$30 Copay | $50 Copay
Office Visit Primary | Specialist
Deductible & 50% Coinsurance
Deductible & 50% Coinsurance
$15 to $100 Copay
$300
$15 Copay (Teladoc)
$15 Copay (Teladoc)
$0 Copay (Doctor On Demand)
Telemedicine
Not Covered
Not Covered
Not Covered
Deductible & 50% Coinsurance
Deductible & 50% Coinsurance
Urgent Care Visit
$50 Copay
$50 Copay
$50 Copay
$150
Emergency Room Visits Diagnostic Lab (X-Ray, Bloodwork)
$100 copay, then Deductible & 30% Coinsurance
$100 copay, then Deductible & 30% Coinsurance
$500 Copay
$500
Deductible & 50% Coinsurance
Deductible & 50% Coinsurance
$30 Copay
$30 Copay
$0 Copay
$0
$100 Copay then Deductible & 30% Coinsurance Deductible & 30% Coinsurance
$100 Copay then Deductible & 30 % Coinsurance
Deductible & 50% Coinsurance
Deductible & 50% Coinsurance
Advanced Imaging
$100 to $725
$2,175
$2,000 (Inpatient) $850 to $3,000 (Outpatient)
$6,000 (Inpatient) Up to $9,000 (Outpatient)
Inpatient Hospital & Outpatient Facility Inpatient Mental Health Outpatient Mental Health Maternity Care Prenatal visits Childbirth Global fees (Dr) Childbirth Facility fees
Deductible & 30% Coinsurance
Deductible & 50% Coinsurance
Deductible & 50% Coinsurance
Deductible & 30% Coinsurance
Deductible & 30% Coinsurance
Deductible & 50% Coinsurance Deductible & 50% Coinsurance
Deductible & 50% Coinsurance Deductible & 50% Coinsurance
$2,000
$6,000
$30 Copay
$30 Copay
$15 Copay
$150
No Charge $50 Copay Deductible & 30% Coinsurance Deductible & 30% Coinsurance
No Charge $50 Copay Deductible & 30% Coinsurance Deductible & 30% Coinsurance
$150 $5,100
Deductible & 50% Coinsurance
Deductible & 50% Coinsurance
$0 Included in facility fees $900 to $1,700
Rehabilitation Services
$1,500 (Inpatient) $10 to $85 (Outpatient)
Deductible & 50% Coinsurance Deductible & 50% Coinsurance Deductible & 50% Coinsurance
Deductible & 50% Coinsurance Deductible & 50% Coinsurance Deductible & 50% Coinsurance
Physical Therapy Clinic Durable Medical Equipment
$50 Copay
$50 Copay
$10 to $70
$210
Deductible & 30% Coinsurance
Deductible & 30% Coinsurance
Up to $1,000
Up to $2,000
This guide is a summary of the employee benefits provided by Wichita Public Schools. If there is a discrepancy between the benefits illustrated in this guide and the official plan document, the plan document will always govern.
Employee Benefits Guide - 7
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