HighDeductibleBookREVMK.indd

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www.myuhc.com Network Out-of-Network Deductible $5,600 / Single $11,200 / Single

Text $11,200 / Family $22,400 / Family CoinsuranceReimbursement 100% Reimbursement 80% Reimbursement Out of Pocket Plan Year Maximum $5,600 / Single $12,400 / Single $11,200 / Family $44,800 / Family Lifetime Maximum Unlimited Physician Services DeductibleApplies • Office Visit DeductibleApplies • Specialists • Virtual Visits

• Routine Physicals Deductible Waived / No Copays Inpatient Hospital Services • Facility DeductibleApplies DeductibleApplies • Physician Services 100% Reimbursement 80% Reimbursement

Text 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

Mental Health / SubstanceAbuse • Inpatient DeductibleApplies DeductibleApplies • Outpatient 100% Reimbursement 80% Reimbursement Prescription Drugs Tier 1 Tier 2 DeductibleApplies Tier 3 100% Thereafter Tier 4

• Physician OfficeVisits DeductibleApplies DeductibleApplies • Hospital Services 100% Reimbursement 80% Reimbursement

80% Reimbursement

100% Reimbursement

100% Reimbursement

100% Reimbursement

Includes Deductible, Medical Copays , Office Visit Copays, & RX Copays