Your Medical Benefits and Contributions CSHL health plans are administered by United Healthcare (UHC). Medical Insurance United Healthcare Choice Plan Choice Plus Plan Member pays: Member pays: Medical Benefits In-Network Out-of-Network In-Network Out-of-Network Preventive Services No charge No coverage No charge 30% after DED Primary Care Provider (PCP) Office Visit: $40 No coverage $40 30% after DED Specialist Office Visit: $70 No coverage $40 30% after DED Physical Therapy $20 No coverage $20 30% after DED Urgent Care Facility $100 No coverage $100 30% after DED Emergency Room $300 No coverage $300 $300 Inpatient Hospital $500 per admission No coverage $1,000 per admission 30% after DED Deductible (DED) : Single/Family (calendar year) $500/$1,000 No coverage $600/$1,300 $1,000/$2,400 Coinsurance See below No coverage 30% 30% Outpatient Surgery: Alternate Facility $300 No coverage 30% after DED 30% after DED
Hospital Based
$300
No coverage
30% after DED
30% after DED
Laboratory Services:
Alternate Facility
$50
No coverage
30% after DED
30% after DED
Hospital Based
$50
No coverage
30% after DED
30% after DED
Radiology Services:
X-rays/Sonograms Complex Imaging
$50
No coverage No coverage No coverage
30% after DED 30% after DED $5,000/$10,000
30% after DED 30% after DED $6,500/$13,000
$300
Out-of-Pocket Maximum
$5,000/$10,000
Prescription Drug Benefits – Tier 1 / Tier 2 / Tier 3
$10/$40/$60 GLP-1 $100 $20/$80/$120
$10/$40/$60 GLP-1 $100 $20/$80/$120
Retail (up to 31 days)
No coverage
$10/$40/$60
Mail Order (up to 90 days)
No coverage
No coverage
Specialty Drugs
Need to be obtained through OptumRx
Employee Monthly Pre-Tax Contributions Choice Plan Full-Time Choice Plan Part-Time
Choice Plus Plan Full-Time
Choice Plus Plan Part-Time
Employee Only
$170.50
$249.00
$400.00
$499.00
Employee+Spouse/Domestic Partner
$332.50
$486.00
$799.00
$998.00
Employee + Child(ren)
$287.50
$420.50
$763.50
$953.50
Employee + Family
$501.50
$734.50
$1,178.00
$1,471.50
For more information on your plan benefits please see your Summary of Benefits Coverage (SBC) and/or Summary Plan Description (SPD) which can be found on the HR Intranet. To locate participating UHC providers or to access the Prescription Drug List, visit www.myuhc.com.
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