1. health and fitness
2. drugs

(changes are in red)
UAMS Medical Plans
Comparison Chart
July 2015
This is not a legal document. Complete benefit
descriptions and exclusions are contained in the
Summary Plan Description, www.hr.uams.edu.
CLASSIC and POINT OF SERVICE
# 1 and # 2 benefits are the same for both plans
POINT OF
SERVICE only
#1
#2
In-Network
Out-of-Network (l)
Lowest cost when you
come to UAMS*
Next lower cost when you
go to UMR-UA System
Network provider
Must be enrolled in POS
plan; no out-of-network
coverage under Classic
paid in full
paid in full
ded + coins
not covered
Covered in full, you pay $0 if you go in-network (columns # 1 and # 2 only)
Preventive Care Services (a)
paid in full
Annual Physical Exam
paid in full
You pay a copay (b) per each in-network visit (columns # 1 and # 2 only)
#3
Additional services such as labs, x-rays and procedures are subject to Deductible and Co-insurance.
Primary Care Doctor
$20 copay (was $10)
$35 copay (was $25)
Specialist Doctor
$35 copay (was $30)
$50 copay (was $45)
Annual Vision Exam (c)
$20 copay (was $10)
$35 copay (was $25)
Outpatient Mental Health/Substance Abuse
$20 copay (was $10)
$35 copay (was $25)
st
nd
nd
ER (copay tiered by visit, waived if admitted)
$150 1 visit, $200 2 visit, $250 after 2 visit
Urgent Care Center Visit
NA
$50 copay
The following are subject to you paying annual Deductible and Co-insurance (Copays may also apply)
Deductible-individual (d) (x 2 if covering family)
$250
$750
Co-insurance (e)
20%
30% (was 20%)
Hospital Inpatient Admission (f)
$150 copay
$300 copay
Prior authorization required
Maternity (g) Applied at hospital admission; no
member cost for covered prenatal care
Outpatient Diagnostic Testing
Outpatient Surgical Services
Outpatient Mental Health Partial
Hospitalization/Intensive Day Treatment
Physical, Occupational & Speech Therapy;
Chiropractic (30 visits combined per year)
Durable Medical Equipment
Ambulance (copay waived if admitted)
Home Health (40 visits per year max)
Hospice
TMJ (h) Must be pre-authorized.
$50 copay
$1,000
40%
+ ded + coins
$300 copay
+ ded + coins
$50 copay per visit
+ ded + coins
$150 copay + ded
+ coins
ded + coins
$100 copay per visit
+ ded + coins
$300 copay + ded
+ coins
ded + coins
$100 copay per visit
+ ded + coins
$300 copay + ded
+ coins
ded + coins
ded + coins
$150 copay + ded + coins
$150 copay + ded + coins
$150 copay
+ ded + coins
$35 office visit copay
(was $25) + ded + coins
ded + coins
$100 copay
ded + coins
ded + coins
$150 copay
+ ded + coins
$200 copay
+ $1,000 ded + coins
$200 copay
+ $2,000 ded + coins
$4,750 per calendar
year, reduced to $2,850
if completed wellness (j)
$8,000
NA
$20 office visit copay
(was $10)+ ded + coins
NA
NA
NA
NA
NA
(benefits now available in Classic)
Out of Pocket Maximum for covered medical services listed above
Individual Medical (i) (x 2 if covering family)
All member out-of-pocket (OOP)costs covered under
the plan accumulate to the maximum OOP costs. OOP
costs for excluded services do not accumulate. to the
OOP maximum.
Same as # 1 and # 2
+ ded + coins
Must be pre-authorized. If emergency, report to UMR
within 24 hours.
Advanced Imaging (e.g. MRI, CT, PET)
ded + coins
ded + coins
$35 copay (was $25)
ded + coins
$4,250 per calendar
year, reduced to $2,350
if completed wellness (j)
ded + coins
ded + coins
$100 copay
ded + coins
ded + coins
*Please note that all services may not be available (“NA”) under SMARTCARE.
Prescription Drugs Copay (k)
$15 tier 1 / $50 tier 2 (was $40) / $80 tier 3
$18.50 / $53.50 / $83.50
Out of Pocket Maximum for covered pharmacy
$1,600 per covered member per calendar year, $3,200 per family (separate, additional maximum from medical out of pocket expenses)
(changes are in red)
(a) Preventive care services from an In-Network provider include:

Well baby/child visits from birth until the day the child attains age 19

Preventive care services and cancer screenings per the U.S. Preventive Task Force Recommendations. See the Summary Plan Description
for details on coverage.
Note that mammograms and nutritional counseling/weight management are not covered if you go out-of-network.
(b) Co-Payment (“copay”) means a fixed dollar amount that you must pay each time you receive a particular medical service. You pay a copay
when you obtain health care directly from your Network Primary Care Physician (PCP) or Network Specialist. Referrals are NOT required for
Network Specialist office visits.
(c) One routine eye exam is covered each calendar year when you must see an in-network Ophthalmologist or Optometrist.
(d) Deductible (“ded”) means a fixed dollar amount that you must incur each calendar year before the health plan begins to pay for covered
medical services. In-network deductibles do not apply to out-of-network deductibles and vice versa. Two individual deductibles = family
deductible
(e) Co-insurance (“coins”) means a fixed percentage of charges you must pay toward the cost of covered medical services, after satisfying the
annual deductible.
(f) Maximum combined inpatient copays per calendar year is $1,200 per person (no more than one hospital admission copay per 30 calendar
days).
(g) Pre-natal/Maternity Outpatient care by a physician requires pre-authorization. Once given, authorization covers physician care and one ultra
sound. Additional ultrasounds require pre-authorization. Maternity Inpatient and other services are subject to copay, deductible and coinsurance. It is your responsibility to notify UAMS Human Resources and submit the required enrollment forms within 31 days of the birth or
adoption of your child in order to obtain coverage for your newborn.
(h) The Temporomandibular Joint Dysfunction (TMJ) deductible is separate from and in addition to any other In-Network or Out-of-Network
deductibles. Pre-authorization is required.
(i) Out-of-Pocket Maximum for Medical Benefits is the maximum deductible, co-insurance and co-payments you would pay in any calendar year.
Does not include plan exclusions, limitations, and pharmacy co-payments. The maximum OOP for prescription drugs is a separate OOP from
medical expenses.
(j) Wellness incentive requirements will be announced to employees the prior year and may include one or more of the following: completion of
annual biometric screening, on-line health risk assessment, selection of a Primary Care Physician, preventive care, tobacco free, and
participation in disease management programs. Employees who enroll in the health plan after the annual wellness window will be subject to
the lower OOP max in their first calendar year of coverage. Wellness incentives, including the reduced OOP max, do not apply to retiree,
surviving family or COBRA members.
(k) Copays at non-participating pharmacies will be $18.50 for Tier 1, $53.50 for Tier 2 and $83.50 for Tier 3. If a new enrollee has to fill a
prescription prior to receiving their pharmacy card, they will have to pay the prescription in full, apply for reimbursement, and will be
reimbursed less the $18.50, $53.50 or $83.50 copay. Prescription out of pocket maximum applies only to prescriptions for which a copay
applies; it does not include costs for excluded or non-covered medications or devises.
(l) When you obtain health care through a Non-UA-UMR Provider, your Benefit payments for covered services will be based on the Maximum
Allowable Payment for out-of-network services, as determined by UMR. Charges in excess of the Maximum Allowable Payments do not count
toward meeting the deductible or meeting the limitation on your co-insurance maximum. Non-UA-UMR Providers may bill the patient for
amounts in excess of the Maximum Allowable Payment.
The following procedures will require pre-authorization before the services are rendered:
1. Any admission to Inpatient Facilities or Partial Hospitalization Units
2. Any referral by your PCP to an Out-of-Network Provider
3. Pre-Natal/Maternity Care
4. Home Health Care, Home Infusion Services, or Hospice (inpatient or outpatient)
5. Transplant Services (including the evaluation to determine if you are a candidate for a transplant by a transplant program)
6. All Advanced Imaging (CT, MRI, Thallium Stress Test, PET; go to www.UMR.com for a complete listing), regardless of place of service.
7. MRI of the breast
NOTE: Certain other services have special Pre-authorization requirements: Surgical treatment of TMJ, Accidental Injury to Teeth. Procedures for
testing and treatment of a diagnosed condition are subject to deductible and co-insurance.
University of Arkansas Disease Management Programs:



Tobacco-free 4 life smoking cession program provides free PCP visits and zero copay for Chantix, a medication for nicotine addiction.
Contact Onlife Health at 1-877-369-0285.
Diabetes Management Initiative and Healthy Heart Programs provide the opportunity for zero copays on many generic medications. For
more information on this and other wellness programs, call UMR at 1-866-575-2540.
Nutritional Counseling and Weight Management Services: One annual visit with a dietitian and up to 3 additional visits in conjunction
with health coaching for those who have a BMI of 27 and above. Prior authorization is required and continued approval contingent upon
compliance with health coaching engagement. Metabolic weight loss programs are reimbursable up to $1000/life time for individuals
with a BMI of 30 and above who participate in health coaching (prior authorization required). Call UMR at 1-888-438-6105 for more
information.
BG 4-29-2015