UTMB Multi-Share Plan Benefits

If a benefit is not specifically listed below as a Covered Service then it is not covered under the plan.

Plan Basics
     Plan Year Deductible None
     Members Coinsurance None
     Plan Year Out-of-Pocket Maximum per Person
        Including deductible
     Plan Year Maximum Benefit $50,000
     Lifetime Maximum Benefit $250,000
Hospital Benefits
     Inpatient Hospital Services
      (UTMB Only)
$200 co-payment per day
Maximum FIVE days covered per plan year
     Outpatient Hospital Services
      (UTMB Only)
          Services include: Outpatient or Same Day Surgery
          and  23 hour Observations
$75 co-payment
Maximum TWO services covered per plan year
     Ancillary Services
     (UTMB Only)
          Radiology and Diagnostic Testing
$75 co-payment for the following diagnostic tests:
Maximum ONE screening covered per plan year:
Mammogram*, Colonoscopy or Osteoporosis
$75 co-payment for the following diagnostic scans:
Maximum ONE major image covered per plan year:
MRI, CT or PET scan
     Physical Therapy / Occupational Therapy
       Requested and approved by  PCP
$30 co-payment
Maximum SIX visits covered per plan year
     Emergency Room Visits
       (UTMB Galveston or UTMB Victory Lakes only)
$75 co-payment
Maximum TWO visits covered per plan year

Physician Benefit
     Inpatient Hospital Care
      (UTMB Only)
Maximum FIVE days covered per plan year
     Outpatient Hospital Care
      (UTMB Only)
Maximum TWO visits covered per plan year
     Doctor Office Visits and Urgent Care Visits
       Includes primary care, specialty care, outpatient mental                                                                                                                      health care, routine lab and first maternity visit
$15 PCP & Urgent Care co-payment
$30 Specialist co-payment
Maximum TWENTY visits covered per plan year
     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

Pharmacy Benefits
     Deductible None
     Member Coinsurance None
     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 plan year