MEDICAL INSURANCE
Homes by West Bay offers 3 medical plans from UHC. To find participating providers go to www.myuhc.com and click on “Find a Physician”, choose the appropriate provider type. In Step 2: Insurance Plan Information choose Network name “Choice Plus” for all plans. Complete the remaining selection information and click Search.
The chart below provides a brief comparison of the plans. This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
5Q-N Rx 40
0F-8 Rx 40
5P-5 Rx 40
Plan Options:
Base
Mid
High
IN-NETWORK: Plan Year / Contract Year Basis Deductible (Individual / Family)
Calendar Year $2,000/ $4,000 $6,250/ $12,500
Calendar Year
Calendar Year
$1,000 per person
$0/$0
Maximum Out-of-Pocket (Individual/Family)
$3,000/ $6,000
$1,500/ $3,000
Out-of Pocket Max Includes Lifetime Major Medical Maximum
Deductible, Coinsurance, & Copays Deductible, Coinsurance, & Copays Coinsurance and Copays
Unlimited
Unlimited
Unlimited
Coinsurance
50%
100%
80%
Routine Preventive Services Wellness Immunizations Mammography/Colonoscopy CO-PAYS PCP Required / Open Access
Covered 100%
Covered 100%
Covered 100%
Open Access
Open Access
Open Access
Office Visits/Consultations for Illness/Injury
$30 Copay $60 Copay
$25 Copay $50 Copay
$15 copay $30 copay
Specialist Visits
Physician Services (Out of Office)
Covered 50% after deductible Covered 100% after deductible Covered 50% after deductible Covered 100% after deductible Covered 50% after deductible Covered 100% after deductible
Covered 80% Covered 80% Covered 80% $350 copay $100 copay Covered 100% Covered 100% Covered 80%
Inpatient Hospital Outpatient Surgery Emergency Room
$350 Copay $100 Copay
$200 Copay $100 Copay
Urgent Care
OUTPATIENT DIAGNOSTIC SERVICES Lab Services
Covered 100% Covered 100%
Covered 100% Covered 100%
X-Ray Services
Complex Diagnostic PRESCRIPTIONS Retail (30 day supply)
Covered 50% after deductible
Covered 90% after deductible
$10/ $35/ $60
$10 / $35/ $60
$10/ $35/ $60
Mail Order (90 day supply)
2.5 X retail
2.5 X retail
2.5 x retail
OUT-OF-NETWORK:
Deductible (Individual / Family)
$500/$1000 $3500/$7000
Maximum Out-of-Pocket (Individual/Family)
In-Network Only
In-Network Only
Lifetime Major Medical Maximum
Unlimited
Coinsurance
60%
Monthly Premium Base
Monthly Premium Mid
Monthly Premium High
Employee Only
$240.49 $514.65 $490.60 $735.90
$303.78 $650.09 $619.71 $929.57
$348.53 $745.85 $711.00 $1066.50
Employee + Spouse Employee + Child(ren)
Family
6
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