Medical
We are proud to offer you a choice of medical plans that provide comprehensive medical and prescription drug
coverage. The plans also offer many resources and tools to help you maintain a healthy lifestyle. Following is a
brief description of each plan.
Preferred Provider High Deductible Health Plan
Plan Features
Organization (PPO) (HDHP)
Carrier UMR UMR
2025 Offerings $1,750 PPO Plan $3,500 HDHP
100% Coverage for Preventive Yes Yes
Provides coverage for out of network
Yes Yes
providers?
Primary Care Physician (PCP)
No No
Required?
Copay based or deductible / Combination of both copays and deductible/co-
Primarily deductible / coinsurance benefits
coinsurance? insurance benefits
Eligible for tax advantaged account? FSA HSA
- Freedom to seek care from any provider - Freedom to seek care from any provider
of your choice, however seeing in-network of your choice, however seeing in-network
providers proves to be cost beneficial. providers proves to be cost beneficial.
- You pay the full cost of non-preventive - You pay the full cost of non-preventive
health care services until you meet the annual health care services until you meet the annual
deductible. You may also have to pay a fixed deductible.
dollar amount (copay) for certain services. - Once you meet the deductible, you pay a
Other Considerations
- Once you meet the deductible, you pay a percentage of certain health care expenses
percentage of certain health care expenses (coinsurance) and the plan pays the rest.
(coinsurance) and the plan pays the rest. - Once your deductible and coinsurance add
- Once your deductible, copays, coinsurance add up to the out-of-pocket maximum, the plan
up to the out-of-pocket maximum, the plan pays pays the full cost of all qualified health care
the full cost of all qualified health care services services for the rest of the year.
for the rest of the year.
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Medical Plan Comparison
The following is a high-level overview of the coverage available through UMR. For complete coverage details,
please refer to the Summary Plan Description (SPD).
$1,750 PPO Plan $3,500 HDHP
Key Medical Benefits
In-Network Out-of-Network1 In-Network Out-of-Network 1
Deductible (per calendar year)
Individual / Family $1,750 / $2,750 $2,750 / $4,750 $3,500 / $7,000 $7,000 / $14,000
Out-of-Pocket Maximum (per calendar year)
Individual / Family $3,500 / $7,000 $7,000 / $14,000 $5,000 / $10,000 $10,000 / $20,000
Company Contribution to Your Health Savings Account (HSA) (per calendar year; prorated for new hires/newly eligible employees)
Individual / Family N/A $250 / $500
Covered Services
Office Visits (physician/specialist) $30 / $60 copay 40%* 20%* 40%*
Telehealth (physician/ specialist) $40 / $75 copay Not Covered 20%* 40%*
Teladoc 100% Covered (Deductible waived) $10 per occurrence
Routine Preventive Care No charge No charge
Outpatient Diagnostic (lab/X-ray) 20%* 40%* 20%* 40%*
Complex Imaging 20%* 40%* 20%* 40%*
Chiropractic Services $30 copay 4 40%* 20%* 40%*
Ambulance 20%* 20%*
Emergency Room $225 copay 20%*
Urgent Care Facility $75 copay 40%* 20%* 40%*
Inpatient Hospital Stay 20%* 40%* 20%* 40%*
Outpatient Surgery 20%* 40%* 20%* 40%*
Prescription Drugs (Generic / Brand / Non-Formulary / Specialty)2
Rx Out-of-Pocket
Rx Out-of-Pocket Maximum Maximum combined
$1,500 / $3,000 N/A N/A
(Individual/Family) with Medical Out-of-
Pocket Maximum
Retail Pharmacy (30-day supply) $10 / $50 / $75 / $75 Not Covered 20%* Not Covered
Mail Order (90-day supply)3 $20 / $100 / $150 Not Covered 20%* Not Covered
Coinsurance percentages and copay amounts shown in the above chart represent what the member is responsible for paying.
*Benefits with an asterisk ( * ) require that the deductible be met before the Plan begins to pay.
To be eligible for the HSA, you cannot be covered through Medicare Part A or Part B or TRICARE programs. See the plan documents for full details.
1. If you use an out-of-network provider, you will be responsible for any charges above the maximum allowed amount.
2. Specialty drugs must be purchased at Accredo Specialty Pharmacy. These medications are limited to 30 day supplies and are restricted to be mailed only.
3. Mail Order Pharmacy is through ESI Home Delivery
4. 24 visit maximum
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Life Insurance
Basic Life/AD&D
Life insurance provides your named beneficiary(ies) Benefit Amount
with a benefit after your death.
1x annual earnings not to
Accidental death and dismemberment (AD&D) Employee
exceed $55,000
insurance provides specified benefits to you in the
event of a covered accidental bodily injury that
directly causes dismemberment (i.e., the loss of a
hand, foot or eye). In the event that your death occurs
due to a covered accident, both the life and the AD&D
benefit would be payable.
Supplemental Life/AD&D Guaranteed
Benefit Option
(Employee-paid) Issue1
If you determine you need more
than the basic coverage, you may $10,000 increments to the lesser of 5 X BAE to
Employee
purchase additional coverage through 5 times earnings or $250,000 $100,0002
Mutual of Omaha for yourself and
your eligible family members.
$5,000 increments to the lesser
Spouse of 50% of the employee’s benefit $30,000
amount or $100,000
Child(ren) $10,000 age 14 days up to age 26 $10,000
1. During your initial eligibility period only, you can receive coverage up to the
Guaranteed Issue amounts without having to provide Evidence of Insurability (EOI,
or information about your health). Coverage amounts that require EOI will not be
effective unless approved by the insurance carrier.
2. BAE is Base Annual Earnings
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January 1 - December 31, 2025
Cost of Benefits Your contributions toward the cost of benefits are
automatically deducted from your paycheck. The
amount will depend on the plan you select and if you
choose to cover eligible family members.
Medical
Weekly Employee Contribution
Coverage Tier $1,750 PPO Plan $3,500 HDHP
UMR
Employee Only $51.53 $12.20
Employee + Spouse $104.05 $47.70
Employee + Child(ren) $102.47 $46.35
Family $162.37 $77.25
Dental
Weekly Employee Contribution
Coverage Tier
Ameritas
Employee Only $5.09
Employee + 1 $9.68
Family $18.00
Vision
Weekly Employee Contribution
Coverage Tier
Mutual of Omaha
Employee Only $1.38
Employee + Spouse $3.16
Employee + Child(ren) $3.50
Family $5.35
Life/AD&D
Deductions for Life/AD&D are taken from your paycheck. Rates are available during enrollment.
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Important Contacts
Coverage Contact Phone Website
Medical UMR 800-826-9781 [Link]
Dental Ameritas 800-283-9588 [Link]
Vision Mutual of Omaha 877-591-4231 [Link]
Employee Benefits
Flexible Spending Accounts (FSAs)
Corporation
800-272-7255 [Link]
Life/AD&D Mutual of Omaha 877-591-4231 [Link]
Disability Mutual of Omaha 877-591-4231 [Link]
Employee Assistance Program (EAP) HealthJoy 888-731-3327 [Link]
Health Savings Accounts (HSAs) Optum 866-234-8913 [Link]/en/
Voluntary Benefits Mutual of Omaha 877-591-4231 [Link]
Benefits Website
Our benefits website [Link]/cloudservice can be accessed anytime
you want additional information on our benefits programs.
DISCLAIMER: The material in this benefits brochure is
Questions? for informational purposes only and is neither an offer
of coverage or medical or legal advice. It contains only a
partial description of plan or program benefits and does
If you have additional questions, you may also not constitute a contract. Please refer to the Summary Plan
Description (SPD) for complete plan details. In case of a
contact: MyLife Advisors at 855-547-8505 conflict between your plan documents and this information,
the plan documents will always govern.
Annual Notices: ERISA and various other state and federal
laws require that employers provide disclosure and annual
notices to their plan participants. The company will distribute
all required notices annually.
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