UToledo Human Resources

Gold Plan Schedule of Benefits 2026

Gold Plan	Tier 1 - UToledo Health	Tier 2 - In-Network (Medical Mutual SuperMed in Ohio, CIGNA outside Ohio)	Tier 3 - Out-of-Network (may be balanced bill)
Embedded Deductible
Single	$200	$400	$1,200
Single+1 OR Family	$400	$800	$2,400
Coinsurance	95% after ded.	85% after ded.	70% after ded.
Maximum Out of Pocket
Single	$1,300	$2,600	$4,200
Single+1 OR Family	$2,600	$5,200	$8,200
Deductible and Out of Pocket Satisfactions	Tier 1 ded./OOP satisfies Tier 1 and 2	Tier 2 ded./OOP satisfies Tier 1 and 2	Tier 3 ded./OOP satisfies Tier 1, 2, 3
Physician/Office Services
Preventive Health Services	Covered in full, not subject to deductible	Covered in full, not subject to deductible	70% after ded.
Office Visit	$15 copay per visit	$25 copay per visit	70% after ded.
Specialist Visit	$30 copay per visit	$40 copay per visit	70% after ded.
Podiatry Services	$30 copay per visit	$40 copay per visit	70% after ded.
Routine Vision Exam	$15 copay, once per calendar year	$25 copay, once per calendar year	70% after ded.
OB/GYN Visits (Non-Preventive)	$15 copay per visit	$25 copay per visit	70% after ded.
Annual GYN Visit (Preventive)	Covered in full, not subject to deductible	Covered in full, not subject to deductible	70% after ded.
Chiropractic Services (35 visits per member per year)	$15 copay	$25 copay	Not covered
Infertility Services — does not apply to max out of pocket	70% after ded., up to $15,000 per calendar year	70% after ded., up to $15,000 per calendar year	Not covered
Diagnostics
Diagnostic Test (X-ray, lab)	95% after ded.	85% after ded.	70% after ded.
Imaging (CT/PET scans, MRI’s) †PA	95% after ded.	85% after ded.	70% after ded.
Maternity Care
Prenatal and Postnatal	N/A	Covered in full, not subject to deductible	70% after ded.
Delivery	N/A	85% after ded.	70% after ded.
Hospital Services
Inpatient †PA	95% after ded.	$100 copay per admission then 85% after ded.	$250 copay per admission then 70% after ded.
Outpatient	95% after ded.	85% after ded.	70% after ded.
Emergency Room Facility	$200 copay per visit (waived if admitted)	$200 copay per visit (waived if admitted)	$200 copay per visit (waived if admitted)
Urgent Care	N/A	$50 copay per visit	$50 copay per visit
Durable Medical Equipment (subject to Medicare Part B) †PA	95% after ded.	85% after ded.	70% after ded.
Foot Orthotics (subject to Medicare Part B Guidelines) †PA	N/A	85% after ded.	70% after ded.
Prosthetic Devices †PA	N/A	85% after ded.	70% after ded.
Human Organ Transplant †PA	95% after ded.	85% after ded.	Not covered
Bariatric Treatment*	95% after ded.	N/A	N/A
Bariatric Surgery*	70% after ded.	N/A	N/A
Ambulance
Emergency Use	N/A	85% after ded.	85% after ded.
Outpatient Surgical Facility Services
Including Outpatient Surgery Facility Charge	95% after ded.	85% after ded.	70% after ded.
Therapy  Services
Inpatient Rehabilitation †PA up to 60 days per member per calendar year	95% after ded.	85% after ded.	70% after ded.
Outpatient Physical/Occupational/Speech Therapy up to 35 visits per member, per calendar year (combined)	$15 copay	$25 copay	70% after ded.
Skilled Nursing Facility
120 day limit per member, per calendar year †PA	95% after ded.	85% after ded.	70% after ded.
Hospice/Home Health Care
In Lieu of Hospitalization †PA	N/A	85% after ded.	70% after ded.
Mental Health/Substance Abuse
Office Visit, Specialist, Inpatient, Outpatient	Based on service type	Based on service type	Based on service type

*$50,000 lifetime maximum for bariatric services.

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†PA - Prior Authorization Required

Updated 10/1/2025