UMR PPO - Nexus ACO 80/50 SD
Original Implementation Date: 05/01/2018 | Plan Effective Date: 01/01/2024Providers
Under the VEBA UnitedHealthcare PPO plan, members may choose to receive medical services from any licensed physician without a referral. If a member chooses to receive services from a provider in the UMR Tier 1 Physician's network they will have lower out-of-pocket costs than if they receive services from an out-of-network provider.
Plan changes are only allowed during the annual Open Enrollment or within 30 days of a qualifying life event.
How to Find a Doctor
Go to the UMR website:
www.umr.comClick "Find a provider"
Click "UnitedHealthcare Choice Plus Network" from the search directory
Click "View Providers"
Enter zip code or city and state
Type in a provider, service, or condition in the search bar or click on an icon to search by category
Out-of-Pocket Costs
The amounts that a member pays when utilizing services.
Deductible
Annual Medical$2,000 / $4,000
Annual$2,000 / $4,000
Out-of-Network
Out-of-Pocket Max
Annual Medical$5,000 / $10,000
In-Network$5,000 / $10,000
Out-of-Network
Out-of-Pocket Max
Annual Prescription$1,600 / $3,200
In-NetworkN/A
Out-of-Network
PCP Office Visit
$30 Copay
Tier 1 Physicians20% coinsurance
Tier 2 Physicians(after deductible)
50% coinsurance
Tier 3 Physicians(after deductible)
Specialist Office Visit
Referral Required$50 Copay
Tier 1 Physicians20% coinsurance
Tier 2 Physicians(after deductible)
50% coinsurance
Tier 3 Physicians(after deductible)
Preventive Care
Annually$0 copay
Tier 1 Physicians$0 copay
Tier 2 PhysiciansNot Covered
Tier 3 Physicians
Urgent Care
$50 copay
Tier 1 Physician$50 copay
Tier 2 Physician50% coinsurance
Tier 3 Physician(after deductible)
Emergency Care
Waived if admitted$100 copay
Tier 1 Physician$100 copay
Tier 2 Physician$100 copay
Tier 3 Physician
Outpatient Surgery
Visit www.carrum.me/CSVEBA$0 copay
For eligible procedures w/ CHSB precertification$100 copay AND 20% coinsurance
Non-CHSB@ Ambulatory Surgery Center or Physician's Office(after deductible)+$1,000 penalty for eligible procedures obtained without CHSB precertification50% coinsurance
(after deductible)Precertification required
Hospitalization
In-Patient20% coinsurance
(after deductible)50% coinsurance
with Prior Authorization(after deductible)
Radiology
Standard Services:
$0 copay
20% coinsurance
Hospital-based lab or radiology(deductible does not apply)50% coinsurance
(after deductible)Complex (MRI / PET):
20% coinsurance
$100 copay +
20% coinsurance
50% coinsurance
(after deductible)
Eye Health
No Referral RequiredBiennial Eye Exam:
$30 copay
$30 copay
Tier 2 PhysicianN/A
Tier 3 PhysicianAdditional Benefits
Prescriptions (Rx)
Prescription benefits are provided by Express Scripts. Subscribers will receive two prescription ID cards per family.
Chiropractic & Acupuncture
Chiropractic and acupuncture benefits are provided by OptumHealth through the UHC medical plan. Services must be medically necessary and may be subject to prior authorization from OptumHealth.
Members use their medical ID card to access the chiropractic and/or acupuncture benefits.
In-Network: $30 copay
Out-of-Network: 50% coinsurance (after deductible)
Kindbody - Fertility, Family-Building and Menopause Support
California Schools VEBA offers Kindbody as your fertility, family-building, and menopause support benefit!
Copays: Vary
Carrum Health Surgery Benefit
Carrum Health is part of the California PPO plans; All deductibles and coinsurance for members using a Carrum Health Surgery Benefit (CHSB) provider for a scheduled Spine, Orthopedic or Coronary Artery Bypass Graft procedure will be waived.
Members must receive precertification for eligible procedures to avoid a $1,000 penalty.
Precertification:
Call (888) 855-7806 or visit www.carrum.me/CSVEBA
Out-of-Area Services
Subscribers
In or Out-of-State
Urgent Care
Emergency Care
Out-of-Country
Urgent Care*
Emergency Care
Dependents
Out-of-Country
Urgent Care*
Emergency Care
ID Cards
Plan Documents
Summary Plan Description
Summary of Benefits & Coverage