Health Insurance
Enrolling and Changing Your Health Coverage
Employees would be able to either enroll within 2 weeks of hire, during the annual open enrollment or in case of a life-changing event. Employees have 30 days to submit a life-changing event (example: marriage, divorce, birth/adoption of baby); once the 30 days have passed, employees need to wait for annual open enrollment.
Member cards will be mailed to the employee's home address within 10-14 business days. If you do not receive your ID cards, please call UMR directly to request a card. If you enrolled in the health plan and need health care services before receiving your ID card, please contact Clarkson Human Resources at clarksonhr@clarkson.edu.
Provider Network:
Visit providers without referral & PCPs not required. Use the provider search tool at www.umr.com.
Coverage:
- In-Network = Provider has a negotiated rate with UMR
- Deductible: $500 Single / $1,200 Family
- Embedded deductible – each member on the plan does not exceed $500. Maximum Family deductible is $1,200.
- Out-of-Pocket Plan Year Maximum: $3000 Single / $6,000 Family
- Preventative Screenings are covered by the Plan and includes Well-Child Visits, Adult Physicals (One/Contract Year), Screening Mammography,Pap Tests, Immunizations etc. Well Adult and Child Care Visits – covered at 100% once a year annually.
- Deductible then 20% Co-Insurance up to the out-of-pocket plan year maximum
- Once deductible plus the out of pocket maximum is met all claims will be covered at 100% for remainder of plan year
- Out-of-Network = provider does not have a negotiated rate with UMR
- Deductible: $700 Single / $2,100 Family
- Out-of-Pocket Plan Year Maximum: $6000 Single / $12,000 Family
- Preventative Screenings are covered by the Plan and includes Well-Child Visits, Adult Physicals (One/Contract Year), Screening Mammography, Pap Tests, Immunizations etc. Well Adult and Child Care Visits – covered at 100% once a year annually.
- Deductible then 30% Co-Insurance
- Once deductible plus the out of pocket maximum is met all claims will be covered at 100% for remainder of plan year
In-Network deductibles/out-of-pocket maximums are separate from Out-of-Network deductibles/out-of-pocket maximums per plan year. TWO individual amounts.
| Service | In-Network | Out-of-Network |
|---|---|---|
| Primary Care & Specialist | Deductible & Co-Insurance | Deductible & Co-Insurance |
Deductible
Out-of-Pocket Maximum | $500 Single / $1,200 Family
$3,000 Single / $6,000 Family | $700 Single / $2,100 Family
$6,000 Single / $12,000 Family |
| Coinsurance | 20% after deductible | 30% after deductible |
| OptumRX | www.optumrx.com Phone: 1-855-295-9136 | |
| Pharmacy (Rx) | Generic 10% Co-pay, $10 Min - $50 Max Preferred 20% Co-pay, $15 Min - $50 Max Non-Preferre 50% Co-pay, $35 Min - $75 Max Specialty 20% Co-pay, $75 Max after Assist | No Coverage Out-of-Network |
| Home Delivery | 90-Day Supply, Max is 2x Retail | No Coverage Out-of-Network |
| Rx Out-Of-Pocket Max | $2,000 Single / $4,000 Family | N/A |
Premiums:
*For part-time Employees working 17.5 - 29 hours weekly the premium rates are doubled bi-weekly.
| Tier 1 - Under 35k | FY2024 |
|---|---|
| Per Pay Period | |
| Employee Only | $36.28 |
| Employee + Spouse | $126.15 |
| Employee + Child(ren) | $114.13 |
| Family | $154.53 |
| Tier 2 - 35k to 50k | FY2024 EE |
|---|---|
| Per Pay Period | |
| Employee Only | $40.06 |
| Employee + Spouse | $140.29 |
| Employee + Child(ren) | $126.92 |
| Family | $177.36 |
| Tier 3 - 50k to 75k | FY2024 EE |
|---|---|
| Per Pay Period | |
| Employee Only | $45.20 |
| Employee + Spouse | $159.66 |
| Employee + Child(ren) | $144.46 |
| Family | $201.86 |
| Tier 4 - 75k to 120k | FY2024 EE |
|---|---|
| Per Pay Period | |
| Employee Only | $49.61 |
| Employee + Spouse | $176.31 |
| Employee + Child(ren) | $159.52 |
| Family | $222.91 |
| Tier 5 - 120k tp 200k | FY2024 |
|---|---|
| Per Pay Period | |
| Employee Only | $54.07 |
| Employee + Spouse | $193.97 |
| Employee + Child(ren) | $175.49 |
| Family | $245.23 |
| Tier 6 - 200k and up | FY2024 EE |
|---|---|
| Per Pay Period | |
| Employee Only | $56.66 |
| Employee + Spouse | $207.89 |
| Employee + Child(ren) | $188.09 |
| Family | $262.83 |
Highlights of the Plan:
1-800-835-2362 / www.Teledoc.com
- $10 Co-pay at time of call; does not apply to deductibles or out-of-pocket maximums.
- Available 24/7/365
- Alternative to receive care. Visit the doctor from home, office or on the go for non-emergency medical conditions or behavioral health services.
- Use when traveling or if primary care doctor is not available instead of going to urgent care or the ER.
- Members must set up an account on the tele-doc website prior to calling.
- Telemedicine Program: Physicians will diagnose your symptoms, prescribe a medication (when appropriate) and send prescription to the nearest pharmacy.
- Common Conditions Treated: allergies, asthma, bronchitis, cold/flu, diarrhea, ear infections, fever, headache, infections, insect bites, joint aches, rashes, sinus infections, skin infections and sore throat
- Behavioral Health Services: Speak with a licensed therapist from anywhere. Confidential treatment, flexible scheduling, quick access to the right provider for you.
1-855-295-9136 / www.optumrx.com
- Medication Adherence Program: Will review specific pharmacy fills for hypertension, hyperlipidemia and other chronic conditions.
- Diabetes Management Program:
Provide education as well as supplies and internet-based meters for high-risk members.
*OptumRX will reach out to all members who will be positively impacted by these programs to make sure they are aware of the program and how it works for them.
Formulary:
- List of all the medications covered by the plan and updated in January & July.
- The list can be located in the Benefit Solver Portal or by visiting www.optumrx.com.
- Co-pay/Coinsurance is determined by type of Medication Tier
- Generics - safe, effective & have the same active ingredients as a brand name medication, but cost an average of 85% less (brands with expired patents)
- Preferred - lower cost or more clinically effective than non-preferred or excluded
- Non-Preferred - highest cost or medications with clinical alternatives
- Specialty - high complexity medications purchased through a specialty pharmacy
- Excluded - medications with clinical alternatives or generics not covered by the plan. Members choose an alternative therapy