MEDICAL UnitedHealthcare
UnitedHealthcare Choice+ HDHP is a qualified HSA plan and provides in/out-of-network benefits. You can receive care from a non-participating health provider, but you will receive a lower level of benefits. Staying in-network when possible ensures that you receive higher level of benefits. If you choose this plan, you will be automatically enrolled in Loomis HSA Compatible GAP plan which provides reimbursement of inpatient hospital and outpatient medical expenses you may incur using your UnitedHealthcare primary coverage. Loomis GAP benefits kick in once you have met the minimum plan deductible threshold set by IRS rules on HSA qualified HDHP. Remaining qualified out-of-pocket expenses will be covered under GAP. To search for a UnitedHealthcare Choice+ HDHP provider, visit myuhc.com and select “ Find a Doctor .” Follow the prompts and choose the plan’s network - Choice Plus.
UnitedHealthcare HDHP/HSA
Loomis Medical GAP HSA Compatible Plan Per Insured DED Limit $1,600 / $3,200
Provider Network
Choice Plus In-Network
Benefits
Calendar Year Deductible (DED) Individual / Family (Emb)
After $1,600 / $3,200 minimum deductible amount is met, GAP plan starts to cover additional out of pocket expenses up to max benefit. Combined Inpatient / Outpatient Benefit
$7,000 / $14,000
Out-of-Pocket Maximum
Individual / Family
$7,000 / $14,000
$5,400 / $10,800
Member Coinsurance
0%
0%
Office Visits
Excluded
Preventive & Wellness Care
100% covered 0% after ded 0% after ded 0% after ded
Telemedicine
not covered
Primary Care Physician
Specialist
Non-Emergent Care
Excluded
Convenience Care Clinic
0% after ded
Emergency Care Emergency Room
Covered
0% after ded 0% after ded
outpatient benefit
Urgent Care
Hospital Services
Covered
Inpatient Care
0% after ded 0% after ded
inpatient benefit outpatient benefit
Outpatient Surgery
Independent Diagnostic Facility
Covered
Labs & X-Rays
0% after ded 0% after ded
outpatient benefit
Diagnostics & Complex Imaging
Prescription Drugs (retail 30 day supply)
Excluded
Tier 1 / Generic
0% after ded 0% after ded 0% after ded 0% after ded 0% after ded
Tier 2 / Brand & Generic Equivalent Tier 3 / Non-preferred Brand Tier 4 / Specialty & Injectables
Prescriptions are not eligible as a covered expense under a gap plan
Mail-Order (90 day supply)
Excluded Excluded
Out-of-network
Deductible (Individual / Family)
$14,000 / $28,000
Member Coinsurance
50%
not covered
Out-of-Pocket Maximum (Individual / Family) $24,000 / $48,000 *Designated Diagnostic Providers (DDP) – are outpatient imaging service providers that meet certain quality and efficiency requirements. To ensure you receive the highest level of coverage, you must use an in-network DDP, otherwise you will have a higher cost-share and end up paying more out-of-pocket for those services. 8
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