MEDICAL INSURANCE
Kisinger Campo & Associates offers medical coverage through United Healthcare (UHC). You have three plan options to choose from. To find participating providers go to www.myuhc.com and click on “Find a Doctor”, then follow the prompts to complete the search within the “Choice/Choice Plus” network. The chart below provides a brief overview of the medical plans offered.
HMO Choice S56
Choice Plus O74
HDHP / HSA
IN-NETWORK DEDUCTIBLE (your first dollar cost for covered in-network claims) Deductible (Individual / Family)
$1,750 / $3,500
$0 / $0
$500 / $1,000
COINSURANCE (your responsibility on claims costs once you’vemet the deductible) 0% OUT OF POCKET MAXIMUM (once met all in-network covered services are covered by the plan) MaximumOut-of-Pocket (Individual / Family) $2.500 / $5,000
0%
0%
$2,500 / $5,000
$500 / $1,000
Maximum Includes
Deductible, Coinsurance, Prescription Costs & Copays
PREVENTIVE CARE Wellness, Immunizations, Mammography, Colonoscopy, etc.
Covered 100%, no cost to you
OFFICE VISITS Referral Required
No
Virtual Visits (refer to page 5)
Up to $50
$15 Copay
$25 Copay
Office Visits (Illness/Injury)
Covered 100% AFTER deductible
$15 Copay
$25 Copay
Specialist Visits
Covered 100% AFTER deductible
$25 Copay
$25 Copay
HOSPITAL SERVICES Inpatient Hospital
Covered 100% AFTER deductible
$500 Copay per admission
Covered 100% AFTER deductible
Outpatient Surgery
Covered 100% AFTER deductible
$250 Copay
Covered 100% AFTER deductible
Emergency Room
Covered 100% AFTER deductible
$150 Copay
$100 Copay
Urgent Care
Covered 100% AFTER deductible
$25 Copay
$50 Copay
DIAGNOSTIC TESTING Lab & X-Ray Advanced Imaging (MRI, CAT, PET, etc.)
Covered 100% AFTER deductible
Covered 100%
Covered 100%
Covered 100% AFTER deductible
$250 Copay
Covered 100% AFTER deductible
Medical deductible FIRST then,
PRESCRIPTIONS
Retail (30 day supply) Tier 1 / 2 / 3
$10 / $30 / $50
$10 / $30 / $50
$10 / $30 / $50
Medicare (Part D) Creditable
Yes
Yes
Yes
OUT–OF-NETWORK
Refer to plan summary for details . Copies can be found within forms library on the Benefits Portal.
Deducible Out of Pocket
$3,500 / $7,000 $10,000 / $20,000
$1,000 / $2,000 $11,000 / $22,000
None
Bi-Weekly Cost for Coverage
Employee Only
$56.98
$72.79
$152.18
Employee + Spouse
$203.99
$265.48
$440.37
Employee + Child(ren)
$191.07
$260.39
$414.61
Employee + Family
$335.20
$456.81
$713.17
1 Charges are subject to balance billing
3 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.
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