MEDICAL UNITEDHEALTHCARE
Your medical benefits are provided by UHC and provides coverage for both in-network and out-of- network providers. You will always have stronger benefits when visiting in-network providers. Please visit the www.uhc.com website or call them at 800-357-0978.
Medical
HSA 3500
HMO 5000
HMO 1500
PPO 1500
In-network
In-network
In-network
In-network
Out-of-network
Annual deductible (Individual/Family)
$3,500/$7,000 $5,000/$10,000 $1,500/$4,000 $1,500/$,4,500 $4,000/$8,000
Out-of-pocket maximum (Individual/Family)*
$6,500/$13,100 $6,350/$12,700 $6,350/$12,700 $4,000/$8,000 $8,000/$16,000
Member Coinsurance
20%
30%
20%
20%
40%
Physician Office Visit/Exam
20% after ded
$30 copay
$30 copay
$30 copay
40% after ded
Outpatient Specialist Visit
20% after ded
$55 copay
$60 copay
$60 copay
40% after ded
Telehealth
Covered 100% $30 copay
$30 copay
$30 copay
40% after ded
Preventive services
Covered 100% Covered 100% Covered 100% Covered 100% Covered 100%
Inpatient hospital services
20% after ded 30% after ded 20% after ded 20% after ded 40% after ded
Outpatient hospital services (lab, x-ray, diagnostic)
20% after ded 30% after ded Covered 100% Covered 100% 40% after ded
Advanced diagnostics
20% after ded 30% after ded
$250 copay
$250 copay
40% after ded
Urgent care
20% after ded
$60 copay
$50 copay
$50 copay
40% after ded
Emergency room care
20% after ded
$350 copay
$400 copay
$400 copay
$400 copay
Prescription drugs Retail (30-day supply) T1/T2/T3/T4*
20% after ded
$10
30% after ded
$10 / $35 / $70 Not Covered
Mail order (90-day supply)
$25 / $87.50 / $175
T1/T2/T3/T4*
20% after ded
$25
30% after ded
Not Covered
* Tier 1 / Tier 2 / Tier 3 / Tier 4 This is a summary of coverage; please refer to your summary plan description for the full scope of coverage. In-network services are based on negotiated charges; Out-of-network services are based on a percentage of Medicare charges.
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