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UMR
PRESTACIONES M
É
DICAS
- UnitedHealthcare
sitios Web del Departamento de Prestaciones
.
Magellan Rx -
Prestaciones de Plan de Medicamentos Recetados
PPO 500
PPO 1500
HDHP 3000
Individual
$500
$1,500
$3,000
$1,000
$3,000
$6,000
Out-of-Pocket Maximum
Individual
$2,500
$4,000
$3,000
$5,000
$8,000
$6,000
$
30 copa
go
$
30 copa
go
$50 copa
go
$50 copa
go
Servicios Laboratorio y Rayos X (en
$75 copa
go
+ 20%*
$75 copa
go
+ 20%*
Radiolog
í
a (esc
á
n especializado)
$100
$1
00
Servicios Paciente Hospitalizado
Hospitaliza
ci
ó
n
$300 cop
ago
admi
si
ó
n
+ 20%*
$300
copago por
admis
i
ó
n
+ 20%*
$250 copa
go
;
exento
$250 copa
go
;
exento
Sin
cargo despu
é
s deducible
Atenci
ó
n Urgente
$50 copa
go
$50 copa
go
*
Esto se aplica después de completar su deducible.
Retail (30 day)
Mail Order (90 day)
HDHP
Generic – Tier 1
$10
$20
Sin cargo despu
é
s deducible
$25
$50
No Disponible
Sin cargo despu
é
s deducible
Non-Preferred Brand – Tier 3
$50
$100
No charge after deductible
Specialty (Pre-Authorization required)
$50/100/150/200
Benefits
Lifetime Maximum
Lifetime Maximum
Unlimited
Unlimited
Unlimited
le
M
á
ximo de por Vida
$
Sin L
í
mite
500
$
Sin L
í
mite
1,500
$
Sin L
í
mite
3,000
Family
$1,000
$3,000
$6,000
Out-of-Pocket Maximum
Individual
Familia
$2,500
$4,000
$3,000
Family
$5,000
$8,000
$6,000
Physician Services
$30 copay
$30 copay
No charge after deductible
Specialist
$50 copay
$50 copay
No charge after deductible
Preventive Benefits
N o ch arge
N o ch arge
No charge
Prestaciones Preventivas
(in
standing facility)
No charge
No charge
No charge after deductible
Outpatient Hospital Facility Services
$75
Sin cargo
$75
Sin cargo
copay + 20%*
Radiology (specialized scanning)
$100 copay
$100 copay
Inpatient Services
$300
copago
coer
$
copago
per
Sin cargo despu
é
s deducible
Emergency Services
Emergency Room
por
ed
if admitted
if admitted
No
Sin cargo despu
é
s deducible
charge after deductible
Urgent Care
$50 copa
charge after deductible
after you reach your deductible.
Por menor
(30 d
''ías
)
Por correo
(90 d
ías
)
HDHP
Gen
é
rico - Nivel
1
$10
$20
Marca Preferida - Nivel
2
$25
$50
No Marca Preferida - Nivel
3
$50
$100
$50/100/150/200
A continuaci
ó
n un resumen breve de las prestaciones del plan en la red: Hay un resumen completo disponible en los
Prestaciones
Máximo de por Vida
Deducible A
ñ
o del Plan
Familia
Servicios de Médicos
Atenci
ó
n Primaria
Sin cargo despu
é
s deducible
Sin cargo despu
é
s deducible
Especialista
Sin cargo
Sin cargo
Sin cargo
Servicios Sin Hospitalización
independiente
oficin del m
é
dico o instalaci
ó
n
Sin cargo despu
é
s deducible
Servicios de Hospital Paciente Externo
Sin cargo despu
é
s deducible
Sin cargo despu
é
s deducible
si es admitido
si es admitido
Servicios de Emergencia
Sala de Emergencia
Sin cargo despu
é
s deducible
Sin cargo despu
é
s deducible
Especialidad (req. autorizaci
ó
n previa)