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BENEFITS
United Healthcare $5000 / HRA
Network
Out-of-Network
Deductible
$3,500 / Single
$7,000 / Single
$7,000 / Family
$14,000 / Family
HRA - Applies after Employee pays $2,500 / Single
deductible and $6,000 / Family Deductible.
$1,000 following Employee Deductible
$1,000 following Family Deductible
N/A
Coinsurance Reimbursement
100% Reimbursement
80% Reimbursement
Out of Pocket Maximum
$6,350 / Single
$12,700 / Family
$16.350 / Single
$32,700 / Family
Includes Deductible, Medical Copays , Office Visit Copays,
& RX Copays
Lifetime Maximum
Unlimited
Physician Services
· Office Visit
$35 Copay
Deductible Applies
· Specialists
•
Virtual Visits
$50 Copay
$5 Copay
70% Reimbursement
· Routine Physicals
Deductible Waived; No Copays
Inpatient Hospital Services
· Facility
Deductible Applies
Deductible Applies
· Physician Services
100% Reimbursement
70% Reimbursement
Outpatient Hospital Services
· Facility
Deductible Applies
Deductible Applies
· Physician Services
100% Reimbursement
70% Reimbursement
· Emergency Services
$200 Copay
$200 Copay
100% Reimbursement
100% Reimbursement
· Urgent Care Services
$75 Copay
Deductible Applies
100% Reimbursement
70% Reimbursement
Maternity Services
· Physician Office Visits
One Time Copay
Deductible Applies;
· Hospital Services
Deductible Applies; 100% Reimbursement
70% Reimbursement
Mental Health / Substance Abuse
· Inpatient
Deductible Applies; 100% Reimbursement
Deductible Applies; 70% Reimbursement
· Outpatient
$50 Copay
Same as Inpatient
· Vision Exam
$25 Copay/1 Exam Every 2 Years
Deductible Applies; 80% Reimbursement
Prescription Drugs
Tier 1
$10
Tier 2
$35
Tier 3
$60
Tier 4
$100
www.myuhc.com