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UnitedHealthcare - Choice Plus PPO - $1,500 Deductible Plan
Benefit Plan
In-Network
Out-of-Network
Deductible
(calendar year)
Single
$1,500
$4,500
Family
$4,500
$13,500
Coinsurance
(plan pays/you pay)
80% / 20%
60% / 40%
Out-of-Pocket Limit
(including the deductible + coinsurance + copayments)
Single
$4,000
$12,000
Family
$12,000
$36,000
Copayments
Primary Physician Visit
$25 Co-Pay
Deductible, then you pay 40%
Specialist Physician Visit
$50 Co-Pay
Deductible, then you pay 40%
Preventive Care
Plan pays 100%
Not Covered
Emergency Room Visit
$200 Co-Pay,
then deductible & coinsurance
$200 Co-Pay,
then deductible & coinsurance
Urgent Care Center Visit
$55 Co-Pay
Deductible, then you pay 40%
Prescription Drug Coverage
Retail Pharmacy
$10/$35/$75/$150
$10/$35/$75/$150
Mail Order Pharmacy
$25/$87.50/$187.50/$375
Not Covered
$1,500 Deductible PPO Plan
Actives
Monthly
EE Cost
Employee Only
$15.49
Employee & Spouse
$341.01
Employee & Child(ren)
$210.71
Employee & Family
$573.37
2 City EEs Married/Dom Part w/full
family coverage
$62.25
$1,500 Deductible PPO Plan
Pre 65 Retirees
Monthly
Cost
Single Only
$742.53
Single & Spouse
$1,514.78
Single & Child(ren)
$1,232.63
Full Family
$2,153.37