Text
Text
Text
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 Pocket
Plan Year Maximum
$5,600 / Single
$12,400 / Single
Includes Deductible, Medical Copays , Office Visit
Copays, & RX Copays
$11,200 / Family
$44,800 / Family
Lifetime Maximum
Unlimited
Physician Services
DeductibleApplies
100% Reimbursement
100% Reimbursement
100% 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 Drugs
Tier 1
Tier 2
DeductibleApplies
Tier 3
100% Thereafter
Tier 4