CopayBook.indd

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Txt $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; Text Coinsurance Reimbursement 100% Reimbursement 80% Reimbursement Out of Pocket Maximum $6,350 / Single $12,700 / Family $16.350 / Single

Text BENEFITS United Healthcare $5000 / HRA Network Out-of-Network Deductible $3,500 / Single $7,000 / Single $7,000 / Family $14,000 / Family

· Inpatient Deductible Applies; 100% Reimbursement Deductible Applies; 70% Reimbursement · Outpatient $50 Copay Same as Inpatient

Text · Hospital Services Deductible Applies; 100% Reimbursement 70% Reimbursement Mental Health / Substance Abuse

www.myuhc.com

· 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

$1,000 following Employee Deductible $1,000 following Family Deductible

HRA - Applies after Employee pays $2,500 / Single deductible and $6,000 / Family Deductible.