MEDICAL INSURANCE
MicroLumen offers medical coverage through United Healthcare (UHC), this benefit is paid for 100% by MicroLumen. 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 Plus” network. The chart below provides a briefly overview of the medical plan offered.
You, and each of your covered dependents, are each responsible for the first $500 of the deductible. Once each of you has satisfied this amount MicroLumen’s HRA will being to pay for the cost of covered services, up to $3,500 per individual. The HRA is administered by UHC, the HRA will automatic pay your providers once the claim is processed.
PPO Network: Choice Plus
IN-NETWORK: DEDUCTIBLE: Plan Year or Calendar Year Basis
Calendar Year
Deductible (Individual / Family)
$4,000 / $11,200
COINSURANCE:
100% / 0%
OUT OF POCKET MAXIMUM: Maximum Out-of-Pocket (Individual/Family)
$5,000 / $12,000
Maximum Includes
Deductible, Copays, & Prescription Copays
PREVENTIVE CARE: Wellness
Immunizations Mammography/Colonoscopy OFFICE VISITS: Referral Required
Covered 100%
No
Office Visits (Illness/Injury)
$20 Copay
Specialist Visits
$40 Copay
HOSPITAL SERVICES: Inpatient Hospital
Deductible
Outpatient Surgery
Deductible
Emergency Room
$200 Copay
Urgent Care
$75 Copay
DIAGNOSTIC TESTING: Independent/Freestanding Lab
Covered 100%
Complex Diagnostic
Deductible
PRESCRIPTIONS: Retail (30 day supply) Tier 1 / 2 / 3 OUT-OF-NETWORK 1 Deductible (Individual / Family) Maximum Out-of-Pocket (Individual/Family)
$10 Copay / $35 Copay / $60 Copay
$5,000 / $10,000
$6,250 / $12,500
Coinsurance
70% / 30%
1 Charges are subject to balance billing 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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