Surest PPO (OOA)
FOR ACTIVE EMPLOYEES' ELIGIBLE DEPENDENTS OR RETIREES / COBRA MEMBERS LIVING OUT-OF-AREAOriginal Implementation Date: 05/01/2018 | Plan Effective Date: 01/01/2024Providers
Active Employees
Employees / subscribers enrolled in a VEBA UnitedHealthcare HMO medical plan with covered eligible dependents living out-of-state will have their dependent enrolled in the UnitedHealthcare Surest PPO Out-of-Area plan at no additional cost.
The employee / subscriber must update their online enrollment with the dependent's correct out-of-state address within 30 days of the move out-of-area.
Retirees & COBRA Members
Retirees & COBRA members must provide PayFlex/ Inspira with their non-California home address AND their request to change plans within 30 calendar days of moving out-of-state. Cannot add this coverage if not currently enrolled in a District-sponsored medical plan.
How to Search for a Doctor or Services
VEBA - UMR_Surest_How to Search Flyer.pdfOut-of-Pocket Costs
The amounts that a member pays when utilizing services.
Deductible
Annual MedicalNone
Out-of-Pocket Max
Annual Medical$1,500
In-Network$8,000
Out-of-Network
Out-of-Pocket Max
Annual Prescription$1,600
In-NetworkN/A
Out-of-Network
PCP Office Visit
$5 - 25 copay
In-Network$75 copay
Out-of-Network
Specialist Office Visit
$5 - 25 copay
In-Network$75 copay
Out-of-Network
Preventive Care
Annually$0 copay
In-Network$40 copay
Out-of-Network
Urgent Care
$10 copay
In-Network$30 copay
Out-of-Network
Emergency Care
Waived if admitted$100 copay
In-Network$100 copay
Out-of-Network
Outpatient Surgery
www.carrum.me/CSVEBA$0 copay
For eligible procedures w/ CHSB precertification$5 - $1,200 copay
Non-CHSB+$1,000 penalty for eligible procedures obtained without CHSB precertificationup to $3,600 copay
Out-of-NetworkPrecertification required
Hospitalization
In-Patient$75 - $1,200 copayIn-Network
up to $3,600 copay
Out-of-Network
Radiology
Standard Services:
$0 copay
$0 copay
Out-of-NetworkNon-routine Diagnostic:
Preauthorization required$5 - $290 copayIn-Networkup to $870 copay
Out-of-NetworkComplex (MRI / PET):
Preauthorization required$25 - $180 copayIn-Network$480 - $540 copayOut-of-Network
Eye Health
Biennial Eye Exam:
$5 - 25 copay
N/A
Out-of-NetworkAdditional Benefits
Prescriptions (Rx)
Prescription benefits are provided by Express Scripts. Subscribers will receive two prescription ID cards per family.
VEBA_2024 01 01_SBC ESI Rx Plan 34_$5.$10.$30_Oceanside.pdfChiropractic
Chiropractic 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 benefit.
Copay same as parent's VEBA-sponsored medical plan's copay
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
ID Cards
Plan Documents
Summary Plan Description
Summary of Benefits & Coverage