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P A G E 2
M
EDICAL
B
ENEFITS
D
ESCRIPTION
B E N E F I T S P L A N O V E R V I E W
Plan Design
United Healthcare
Choice HMO
HSA Compatible
United Healthcare
Choice Plus POS
HSA Compatible
Deductible:
In-Network
In-Network
Out-of-Network
- Single
$1500
$1,300
$2,000
- Family
$4,500
$2,600
$4,000
Out of Pocket Maximum:
In-Network
Out-of-Network
- Single
$6,000
$2,600
$6,000
- Family
$6,850
$5,200
$12,000
Coinsurance:
70%
90%
70%
Office Visits:
Deductible First
Deductible First
Deductible First
- Primary Care Physician
30%
10%
30% Allowed Benefit
- Specialist
30%
10%
30% Allowed Benefit
- Lab and x-ray (free standing)
30%
10%
30% Allowed Benefit
Preventive Service
Deductible Does Not
Apply
Deductible Does Not
Apply
Deductible First
- Well Child
No Charge
No Charge
20%
- Adult
No Charge
No Charge
20%
Hospitalization:
Deductible First
Deductible First
Deductible First
- Inpatient
30%
10%
30% Allowed Benefit
- Outpatient
30%
10%
30% Allowed Benefit
- Urgent care
30%
10%
Same as in network
- Accident/Medical Emergency
(Copay Waived if Admitted)
30%
10%
Same as in network
Prescription Drugs:
Integrated Medical/Rx
Deductible
Integrated Medical/Rx
Deductible First
Integrated Medical/Rx
Deductible First
- Generic / Tier 1
$10 Copay
$10 Copay
$10 Copay
- Brand / Tier 2
$40 Copay
$40 Copay
$40 Copay
- Non-Formulary / Tier 3
$75 Copay
$75 Copay
$75 Copay
- Mail Order (up to 90 days)
2.5 x copay
2.5 x copay
N/A
Primary Physician
No Referral
No Referral
N/A
Physician Network
www.uhc.com www.uhc.comN/A
Lifetime Maximum
Unlimited
Unlimited
Unlimited
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