My Premier Plan Benefits

2019-2020 Plan Year Highlights

The Premier Plan is a Platinum Plan, the highest metallic category established under Federal Regulations.  It includes 90 to 100% of In-network medical and mental health coverage; worldwide coverage; pharmacy coverage; and access to discount dental and vision networks. The Plan is fully insured by United HealthCare (UHC) and is administered by United Healthcare StudentResources.

Exclusions and limitations apply to include Plan Year Deductibles, Co-payments, and Co-insurance. Refer to the Certificate of Coverage for details and below for highlights.  Students will reduce their out-of-pocket covered expenses by going to the providers listed below.

  1. Schedule 1, the Student Health Center (SHC) or Counseling and Psychiatric Service (CAPS), first;
  2. Schedule 2, the UnitedHealthcare Choice Plus National PPO Network (includes Georgetown University Hospital-Medstar), second; or
  3. Schedule 3, the Out-of Network, last.

SCHEDULE 1 (SHC & CAPS), You Pay

  • Co-Payment: $10 for an Outpatient Primary Care or Mental Health Visit

SCHEDULE 2 (In-Network), You Pay

  • Plan Year Deductible: $200
  • Co-Payment: $25 for an Outpatient Physician or Mental Health Visit
  • Co-Payment: $50 for an Urgent Care Visit
  • Co-Insurance: 10%, e.g., labs, tests, inpatient, miscellaneous services

SCHEDULE 3 (Out-of-Network), You Pay

  • Plan Year Deductible: $250
  • Co-Payment: $50 for an Urgent Care Visit
  • Co-Insurance: 30% of Reasonable charges and any remaining charges over and above Reasonable, e.g., physician visits, labs, tests, inpatient, miscellaneous services.

PHARMACY

Details of the UHC drug formulary and corresponding list of drugs assigned to a Tier cost structure are on the UnitedHealthcare StudentResources website at UHCSR.com

  • Plan Year Deductible: $150, separate deductible from medical benefits
  • Co-payment: $15 for covered Tier 1 medications
  • Co-insurance: 20% of Tier 2 and 3 medications, Pre-authorization is required for some specialty medications.

PLAN MAXIMUM

Unlimited

OUT-OF-POCKET MAXIMUM (Medical & Mental Health)

Once a student has met the applicable out-of-pocket maximum indicated below, the Plan pays 100% of covered expenses. 

  •  $5,000 per insured for In-Network benefits not to exceed $10,000 per family
  •  $12,500 per insured for Out-of-Network benefits.