Surest Plan
Surest Plan
Surest Plan
Plan Details
Carrier
Surest
Network
United Healthcare Choice Plus
Plan Type
Copay Plan
HSA Eligible
No
FSA Eligible
Dependent Care FSA
Premiums
| Coverage Tier | Surest Plan — Wellness | Surest Plan — Non-Wellness |
|---|---|---|
| Employee Only | $98.21 | $110.71 |
| Employee + Spouse | $249.62 | $262.12 |
| Employee + Child(ren) | $224.61 | $237.11 |
| Employee + Family | $390.29 | $402.79 |
Employee Only
- Surest Plan — Wellness
- $98.21
- Surest Plan — Non-Wellness
- $110.71
Employee + Spouse
- Surest Plan — Wellness
- $249.62
- Surest Plan — Non-Wellness
- $262.12
Employee + Child(ren)
- Surest Plan — Wellness
- $224.61
- Surest Plan — Non-Wellness
- $237.11
Employee + Family
- Surest Plan — Wellness
- $390.29
- Surest Plan — Non-Wellness
- $402.79
Deductible, Out-of-Pocket & Coinsurance
| Feature | In-Network | Out-of-Network |
|---|---|---|
| Calendar Year Deductible - Individual | $0 | $0 |
| Calendar Year Deductible - Family | $0 | $0 |
| Coinsurance (You Pay) | 0% | 0% |
| Calendar Year Out-Of-Pocket Maximum - Individual | $4,000 | $8,000 |
| Calendar Year Out-Of-Pocket Maximum - Family | $8,000 | $16,000 |
Calendar Year Deductible - Individual
- In-Network
- $0
- Out-of-Network
- $0
Calendar Year Deductible - Family
- In-Network
- $0
- Out-of-Network
- $0
Coinsurance (You Pay)
- In-Network
- 0%
- Out-of-Network
- 0%
Calendar Year Out-Of-Pocket Maximum - Individual
- In-Network
- $4,000
- Out-of-Network
- $8,000
Calendar Year Out-Of-Pocket Maximum - Family
- In-Network
- $8,000
- Out-of-Network
- $16,000
Covered Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Preventive Care | No charge | $100 |
| Primary Care | $10-$65 | $195 |
| Specialist Services | $10-$65 | $195 |
| Virtual Visits | PCP/Urgent: $0Specialty: $10-$40 | N/A |
| Urgent Care | $35 | $105 |
| Diagnostic Tests | $0 | $0 |
| Inpatient Care | $150-$2,500 | Up to $7,000 |
| Outpatient Facility | $75-$525 | $1,575 |
| Emergency Room | $350 | $350 |
Preventive Care
- In-Network
- No charge
- Out-of-Network
- $100
Primary Care
- In-Network
- $10-$65
- Out-of-Network
- $195
Specialist Services
- In-Network
- $10-$65
- Out-of-Network
- $195
Virtual Visits
- In-Network
- PCP/Urgent: $0Specialty: $10-$40
- Out-of-Network
- N/A
Urgent Care
- In-Network
- $35
- Out-of-Network
- $105
Diagnostic Tests
- In-Network
- $0
- Out-of-Network
- $0
Inpatient Care
- In-Network
- $150-$2,500
- Out-of-Network
- Up to $7,000
Outpatient Facility
- In-Network
- $75-$525
- Out-of-Network
- $1,575
Emergency Room
- In-Network
- $350
- Out-of-Network
- $350
Pharmacy Benefits
| Tier | In-Network | Out-of-Network |
|---|---|---|
| Rx Deductible | $150 per individual | $150 per individual |
| Retail Rx (Up To 30-Day Supply) | ||
| Generic | $20 Copay | $20 Copay + 20% |
| Preferred Brand | $50 Copay | $50 Copay + 20% |
| Non-Preferred Brand | $75 Copay | $75 Copay + 20% |
| Mail Order Rx (Up To 90-Day Supply) | ||
| Generic | $40 Copay | Not covered |
| Preferred Brand | $100 Copay | Not covered |
| Non-Preferred Brand | $150 Copay | Not covered |
Rx Deductible
- In-Network
- $150 per individual
- Out-of-Network
- $150 per individual
Retail Rx (Up To 30-Day Supply)
- In-Network
- Out-of-Network
Generic
- In-Network
- $20 Copay
- Out-of-Network
- $20 Copay + 20%
Preferred Brand
- In-Network
- $50 Copay
- Out-of-Network
- $50 Copay + 20%
Non-Preferred Brand
- In-Network
- $75 Copay
- Out-of-Network
- $75 Copay + 20%
Mail Order Rx (Up To 90-Day Supply)
- In-Network
- Out-of-Network
Generic
- In-Network
- $40 Copay
- Out-of-Network
- Not covered
Preferred Brand
- In-Network
- $100 Copay
- Out-of-Network
- Not covered
Non-Preferred Brand
- In-Network
- $150 Copay
- Out-of-Network
- Not covered
Plan Notes
- All services except for preventive are subject to a copay which will vary by provider and service.
- Access the Surest website (https://benefits.surest.com) or mobile app to search for treatment options with transparent and predictable episode of care cost so there are no surprises.
- Lower costs an indication of higher-value care.
- Potential to experience significantly reduced cost depending on network provider selected.