UTMB Multi-Share Plan Provider Network
|Annual Out-of-Pocket Maximum per Person
|Annual Maximum Benefit||$50,000|
|Lifetime Maximum Benefit||$250,000|
|Inpatient Hospital Services (UTMB Only)||$200 co-payment per day
Maximum FIVE days covered annually
|Outpatient Hospital Services (UTMB Only) Services include: Outpatient or Same Day Surgery and 23 hour Observations||$75 co-payment
Maximum TWO services covered annually
|Ancillary Services (UTMB Only) Radiology, Pathology and Diagnostic Testing||$75 co-payment diagnostic x-ray and diagnostic testing
Maximum ONE screening covered annually: Mammogram*, Colonoscopy or Osteoporosis
Maximum ONE major image covered annually: MRI, CT or PET scan
|Physical Therapy / Occupational Therapy Requested and approved by PCP||$30 co-payment Maximum
SIX visits covered annually
|Emergency Room Visits (UTMB, Mainland Medical or Clear Lake Regional Medical Center only)||$75 co-payment Maximum
TWO visits covered annually
*If a screening mammogram is ordered by your PCP in your well-woman exam, the $75 co-payment is not required.
|Inpatient Hospital Care (UTMB Only)||Maximum FIVE days covered annually|
|Outpatient Hospital Care (UTMB Only)||Maximum TWO visits covered annually|
|Doctor Office Visits and Urgent Care Visits
Includes primary care, specialty care, outpatient mental health care, routine lab and first maternity visit
|$15 PCP co-payment $30 Specialist/Urgent Care co-payment Maximum TWENTY visits covered annually|
|Radiology and Pathology
Routine imaging as medically necessary and requested by PCP/Specialist. Does not include MRI, CT or PET scans or other imaging as determined by the Plan
|Co-Payments||$4 generic program through Wal-Mart, HEB, etc.
$25 co-payment for generic
$50 co-payment for non-generic
|Annual Pharmacy Maximum||$1,200 maximum per year|
|Dental and Vision Care||Not Covered|
|Durable Medical Equipment||Not Covered|
|Home Health Care||Not Covered|
(includes prenatal and postpartum care. Only first visit counts towards office visit limits. Does not include expenses related to the baby)
|$200 co-payment per day Maximum of FIVE days inpatient hospital stay|
|Private Duty Nursing||Not Covered|
Covered benefits are specifically listed above; however, below is a partial listing of plan limitations and exclusions, but it is not meant to be an exhaustive list.
Limitation and Exclusions
Unless specifically stated otherwise, no benefits will be provided for or on account of the following items:
- Treatments, services, supplies and/or surgeries that are not medically necessary.
- Services received outside the Multi-Share Plan provider network.
- A sickness or bodily injury that is covered under Worker's Compensation or similar law.
- A sickness or bodily injury arising out of, or in the course of, any employment for wage, gain or profit.
- A sickness or bodily injury arising out of the commission of a crime or ordered by the court.
- Services provided to you, if they do not comply with the plan requirements:
- Service provided by a health care provider that is out-of-network (unless in an emergency situation and if it meets the defined emergency guidelines).
- Received in an emergency room, unless required because of emergency care.
- Any drug, biological product, device, medical treatment, or procedure which is experimental, or investigational or for research purposes.
- Treatment of nicotine habit or addiction.
- Hearing aids, the fitting of aids or advice on their care.
- In-vitro fertilization; any medical or surgical treatment of infertility.
- Treatment of erectile dysfunction or injectable medications.
- Elective sterilization including, but not limited to tubal ligations and vasectomies and the reversal of elective sterilization.
- Cosmetic surgery, unless for reconstructive surgery and is subject to network constraints and plan limitations.
- Appliances or supplies for treatment of teeth, gums, or jaw.
- Custodial care and maintenance care including, but not limited to nursing homes and home health care.
- Inpatient mental health care services and treatment.
- Any treatment, including but not limited to surgical procedures for obesity.
- Services related to allergy testing or treatment.
- Alternative medicine, including but not limited to acupuncture, acupressure, reflexology, therapeutic massage, etc.
- Dialysis treatment and services.
- Any treatment or services relating to end-of-life palliative care including Hospice
- All chiropractic services
- Any human or artificial organ or tissue transplant.
- Speech treatment or services.
- Service and treatment related to intrauterine care, genetics testing and elective termination of pregnancy.
- Implants, injectable and insertables (as related to contraceptive management)
These limitations and exclusions apply even if a health care practitioner has performed or prescribed a medically appropriate procedure, treatment or supply. This does not prevent your health practitioner from providing or performing the procedure, treatment or supply; however, the procedure, treatment or supply will not be a covered expense.
A Pre-Existing Condition is a condition for which medical advice, diagnosis, care or treatment was recommended or received within six months prior to the person's Enrollment Date under this Plan. Genetic Information is not, by itself, a condition. Treatment includes receiving services and supplies, consultations, diagnostic tests or prescribed medicines. In order to be taken into account, the medical advice, diagnosis, care or treatment must have been recommended by, or received from, a Physician. The Pre-Existing Condition does not apply to Pregnancy.
|Physician Visits (Primary/Specialty)||$15/$30||20 Visits/Year|
|Urgent Care Clinic||$30||Incl|
|Emergency Room||$75||No Max|
|Outpatient Surgery||$75||No Max|
|Hospitalization||$200||30 Days/Year or $50,000/Year|
|Scans – MRI, CT, PET||$75||No Outpatient Max|
|Outpatient Mental Health||$30||12 Visits/Year|
|Outpatient Pharmacy through UTMB Pharmacy And & Caremark Network (generic/non-generic)||$25/$50||$1,200/Year|
|Lifetime maximum benefit: $250,000. All specialty care services and hospital admissions must be approved by primary care provider (except emergency or urgently needed services).|