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Progressive Medical, Inc.
5
MEDICAL INSURANCE
Plan E9F Balanced, Rx K4
Benefit / Service
In-Network
Non-Network
Coinsurance
You Pay 20%
After the Deductible
You Pay 50%
After the Deductible
Annual Out-of-Pocket Maximum
Individual / Family
$4,000 / $8,000
$8,000 / $16,000
Office Visit
Primary Care
Specialist
$30 Co-Pay
$60 Co-Pay
You Pay 50%
After the Deductible
Preventive Care
You Pay 0%
No Deductible
You Pay 50%
After the Deductible
Inpatient Hospital
You Pay 20%
After the Deductible
You Pay 50%
After the Deductible
Outpatient Services
Includes X-Ray, Lab, &
Diagnostics
(See Major Diagnostics
)
You Pay 20%
After the Deductible
You Pay 50%
After the Deductible
Major Diagnostics, X-Ray, Lab,
CT, PET, MRI, MRA, & Nuclear
You Pay 20%
After the Deductible
You Pay 50%
After the Deductible
Emergency Room
You Pay $300
Co-Pay Per Service
You Pay $300
Co-Pay Per Service
Urgent Care
You Pay $100
Co-Pay Per Service
You Pay 50%
After the Deductible
Lifetime Maximum
Unlimited
Unlimited
Prescription Drug - Retail
Tier 1
Tier 2
Tier 3
Prescription Drug - Mail Order
90 Day Supply
$10 Co-Pay
$25 Co-Pay
$40 Co-Pay
2.5 Co-Pays
$25 Co-Pay
$62.50 Co-Pay
$100 Co-Pay
Not Covered
Annual Deductible
Individual / Family
$1,000 / $2,000
$3,000 / $6,000
PLAN HIGHLIGHTS
Co-Pays, Coinsurance, Prescription
Drug Co-Pays, and Deductibles
accumulate towards the Out-of-
Pocket Maximum.
Lab, X-Ray, and other preventive
tests for Preventive care are covered
at 100% with no deductible.
You can visit a Walgreens Take
Care clinic for a Primary Care Office
Visit Co-Pay.
If you use a non-network pharmacy
you will be responsible for any
difference between what the
non-network pharmacy charges and
the amount UHC would have paid
for the same prescription drug
product dispensed by a network
pharmacy
.
You should read and review the
certificate of coverage and the
Summary of Benefit and Coverage
to know your exact benefits. You
can also contact United Healthcare
at the phone number on the back of
your ID card.