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UMR High Deductible Health Plans (HDHP) - UHC Choice Plus Network
UMR Medical Plans - UHC Choice Plus Network
Preventive Care
Preventive Care – covered 100% without deductible (Well-women, Well-men, Well-baby Care, Blood Pressure Screening,
Cholesterol Check). For Example: If the physician charge is $300, insurance pays 100% of the bill, leaving you with a $0
balance.
*
An embedded deductible means that one person in a family can meet their individual deductible at which point the health plan will begin paying.
The remainder of the family can make up the remaining portion of the family deductible.
Refer to the Summary Plan description for a complete listing of services, limitations, exclusions and a description of all the
terms and conditions of coverage.
MEDICAL & PHARMACY PLANS
DESCRIPTION OF COVERAGE
HDHP $4,000
HDHP $2,600
In Network
In Network
Deductible/per plan year
*
(Individual • Family)
$4,000 • $8,000
$2,600 • $5,200
Coinsurance
(on allowed amount)
20%
20%
Maximum Out-of-Pocket
(Individual • Family)
(Includes deductible, copayments & coinsurance)
$5,800 • $11,600
$5,000 • $10,000
In Network
In Network
Preventive Care
Covered 100%
Covered 100%
Non-Preventive Visits
(PCP/Specialist)
20% after deductible
20% after deductible
Lab
20% after deductible
20% after deductible
X-Ray
(Excluding Specialty Scans)
20% after deductible
20% after deductible
Major Diagnostic Scans
(MRI • PET • CT)
20% after deductible
20% after deductible
Inpatient Hospitalization
20% after deductible
20% after deductible
Emergency Room
20% after deductible
20% after deductible
Urgent Care
20% after deductible
20% after deductible
Routine Eye Exam -
One every two years
20% after deductible
20% after deductible
PRESCRIPTION DRUGS
Retail
30 day supply
Mail Order
90 day supply
Copays apply to Preventive Therapy Drug List
Visit
caremark.comfor a full list of these prescriptions.
Generic
$10 copay after deductible
$25 copay after deductible
Brand
$30 copay after deductible
$75 copay after deductible
Non-Preferred Brand
$50 copay after deductible
$125 copay after deductible
Specialty
30 day supply, $50 after deductible
DESCRIPTION OF COVERAGE
CLASSIC
PERFORMANCE
In Network
In Network
Deductible/per plan year
*
(Individual • Family)
$3,000 • $6,000
$1,500 • $3,000
Coinsurance
(on allowed amount)
30%
30%
Maximum Out-of-Pocket
(Individual • Family)
(Includes deductible, copayments & coinsurance)
$6,350 • $12,700
$4,500 • $9,000
In Network
In Network
Preventive Care
Covered 100%
Covered 100%
Non-Preventive Visits
(PCP/Specialist)
$25 • $50
$25 • $50
Lab
100% Covered
100% Covered
X-Ray
(Excluding Specialty Scans)
100% Covered
$75
Major Diagnostic Scans
(MRI • PET • CT)
$250
30% after deductible
Inpatient Hospitalization
30% after deductible
30% after deductible
Emergency Room
$250
$250
Urgent Care
$100
$100
Routine Eye Exam -
One every two years
$25
$25
PRESCRIPTION DRUGS
Retail
30 day supply
Mail Order
90 day supply
Generic
$15 copay
$37.50
Brand
$45 copay
$112.50
Non-Preferred Brand
$85 copay
$212.50
Specialty
30 day supply for $170 copay