HighDeductibleBookREV.indd

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www.myuhc.com
Network
Out-of-Network
Deductible
$5,600 / Single
$11,200 / Single
$11,200 / Family
$22,400 / Family
CoinsuranceReimbursement
100% Reimbursement
80% Reimbursement
Out of PocketPlan Year Maximum
$5,600 / Single
$12,400 / Single
Includes Deductible, Medical Copays , Office VisitCopays, & RX Copays
$11,200 / Family
$44,800 / Family
Lifetime Maximum
Unlimited
Physician Services
DeductibleApplies100% Reimbursement100% Reimbursement100% Reimbursement
• Office Visit
DeductibleApplies
•
Specialists
•
Virtual Visits
80% Reimbursement
• Routine Physicals
Deductible Waived / No Copays
Inpatient Hospital Services• Facility
DeductibleApplies
DeductibleApplies
• Physician Services
100% Reimbursement
80% Reimbursement
Outpatient Hospital Services• Facility
DeductibleApplies
DeductibleApplies
• Physician Services
100% Reimbursement
80% Reimbursement
• EmergencyServices
DeductibleApplies
DeductibleApplies
100% Reimbursement
100% Reimbursement
• Urgent Care Services
DeductibleApplies
DeductibleApplies
100% Reimbursement
80% Reimbursement
Maternity Services• Physician OfficeVisits
DeductibleApplies
DeductibleApplies
• Hospital Services
100% Reimbursement
80% Reimbursement
Mental Health / SubstanceAbuse• Inpatient
DeductibleApplies
DeductibleApplies
• Outpatient
100% Reimbursement
80% Reimbursement
Prescription DrugsTier 1Tier 2
DeductibleApplies
Tier 3
100% Thereafter
Tier 4