Your Medical Benefits and Contributions CSHL health plans are administered by United Healthcare (UHC). Medical Insurance United Healthcare Choice Tiered 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: $20 No coverage $40 30% after DED Specialist Office Visit: $35 No coverage $40 30% after DED Physical Therapy $20 No coverage $20 30% after DED Urgent Care Facility $50 No coverage $50 30% after DED Emergency Room $200 No coverage $200 $200 Inpatient Hospital 5% - No DED No coverage $1,000 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 5% - No DED No coverage 30% after DED 30% after DED Hospital Based $250 co-pay per occurrence – 5% No coverage 30% after DED 30% after DED Laboratory Services: Alternate Facility 5% - No DED No coverage 30% after DED 30% after DED Hospital Based 20% after DED No coverage 30% after DED 30% after DED Radiology Services: Alternate Facility 5% - No DED No coverage 30% after DED 30% after DED Hospital Based 20% after DED No coverage 30% after DED 30% after DED Out-of-Pocket Maximum $3,500/$7,000 No coverage $3,500/$7,000 $5,000/$10,000 Prescription Drug Benefits – Tier 1 / Tier 2 / Tier 3 Retail (up to 31 days) $10/$35/$55 No coverage $10/$35/$55 $10/$35/$55 Mail Order (up to 90 days) $20/$70/$110 No coverage $20/$70/$110 No coverage Specialty Drugs Need to be obtained through OptumRx Employee Monthly Pre-Tax Contributions Choice Tiered Plan Full-Time Choice Tiered Plan Part-Time Choice Plus Plan Full-Time Choice Plus Plan Part-Time Employee Only $170.50 $243.00 $371.50 $463.50 Employee+Spouse/Domestic Partner $332.50 $474.00 $742.00 $927.00 Employee + Child(ren) $287.50 $410.00 $709.00 $885.50 Employee + Family $501.50 $716.50 $1,094.00 $1,367.00 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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