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
20% after DED
PCP/Specialist Office Visit: Tier 1 PCP/Specialist Office Visit: Non-Designated
$20
No coverage
$40
20% after DED
$35
No coverage
$40
20% after DED
Physical Therapy
$20 $50
No coverage No coverage No coverage No coverage
$40 $50
20% after DED 20% after DED
Urgent Care Facility Emergency Room Inpatient Hospital
$150 $500
$150
$150
$1,000
20% after DED
Deductible (DED) : Single/ Family (calendar year)
$250/$500
No coverage
$500/$1,200
$1,000/$2,400
Coinsurance
See below
No coverage
20%
20%
Outpatient Surgery:
Alternate Facility
0% - No DED No coverage $250 co-pay per occurrence – 0% No coverage
20% after DED 20% after DED
Hospital Based
20% after DED 20% after DED
Laboratory Services:
Alternate Facility
0% - No DED No coverage 20% after DED No coverage
20% after DED 20% after DED 20% after DED 20% after DED
Hospital Based
Radiology Services:
Alternate Facility Hospital Based
0% - No DED No coverage 20% after DED No coverage
20% after DED 20% after DED 20% after DED 20% after DED
Out-of-Pocket Maximum $3,000/$6,000
No coverage
$3,350/$6,700
$5,000/$10,000
Prescription Drug Benefits – Tier 1 / Tier 2 / Tier 3
Retail (up to 31 days)
$10/$35/$55 $20/$70/$110
No coverage No coverage
$10/$35/$55 $20/$70/$110
$10/$35/$55 No coverage
Mail Order (up to 90 days)
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
$103.00
$178.50
$272.50
$340.50
Employee+Spouse/Domestic Partner
$224.50
$348.00
$544.50
$680.50
Employee + Child(ren) Employee + Family
$195.00 $340.00
$301.50 $526.00
$520.00 $803.00
$650.00
$1,003.50 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 Tier 1 network providers, or to access the Prescription Drug List, visit www.myuhc.com.
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