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The Desco Group
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UNITED HEALTHCARE—DUAL OPTION MEDICAL PLANS
MEDICAL OPTION #1: TRADITIONAL PPO
Benefit/Service
In-Network
Out-of- Network
Deductible
Individual
Family
$1,000
$2,000
$3,000
$6,000
Coinsurance
100%
70%
Out-of-Pocket Max
- Individual
- Family
$4,000
$8,000
$8,000
$16,000
Inpatient Hospital
100% After Deductible
70% After Deductible
Outpatient Hospital
100% After Deductible
70% After Deductible
Office Visit Co-Pay
-PCP/Specialist
$25/$50 Co-Pay
70% After Deductible
Preventive Care
100%
70% After Deductible
Urgent Care
$100 Co-Pay
70% After Deductible
Emergency Room
$300 Co-Pay
$300 Co-Pay
Prescription
Tier One
Tier Two
Tier Three
Mail Order
At Participating Pharmacies:
$10 Co-Pay
$25 Co-Pay
$40 Co-Pay
$25/$62.50/$100 Co-Pay
Employee Only
$60.25
Employee & Spouse
$126.52
Employee & Children
$117.48
Employee & Family
$183.75
MEDICAL OPTION #1: TRADITIONAL PPO
Cost Per Pay Period