MEDICAL INSURANCE
The chart below provides a brief overview of the medical plans. 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.
Jagged Peak offers four medical plans through UMR and uses the UnitedHealthcare provider network. (To find participating providers go to www.umr.com and click on “Find a Provider”, then choose “UnitedHealthcare Choice Plus Network” from the network listing. Then follow the prompts to find a provider in your area.
US – Option 1
US – Option 2
US – Option 3
US – Option 4
IN-NETWORK:
Calendar Year Basis
Calendar Year
Calendar Year
Calendar Year
Calendar Year
Deductible (Individual / Family)
$4,000 / $8,000
$4,000 / $8,000
$2,000 / $4,000
$500 / $1,000
Embedded/Non-embedded
Embedded
Embedded
Embedded
Embedded
Coinsurance
80% / 20%
50% / 50%
80% / 20%
100% / 0%
Maximum Out-of-Pocket (Individual / Family)
$6,000 / $12,000
$6,500 / $13,000
$6,500 / $13,000
$6,500 / $13,000
Deductible, Coinsurance & Copays
Deductible, Coinsurance & Copays
Deductible, Coinsurance & Copays
Out-of-Pocket Max Includes
Deductible and Coinsurance
Lifetime Maximum
Unlimited
Unlimited
Unlimited
Unlimited
Routine Preventive Services
Wellness Immunizations Mammography/Colonoscopy CO-PAYS Telemedicine Program
Covered 100%
Covered 100%
Covered 100%
Covered 100%
$0 Copay – HealthiestYou – Call: 866-703-1259 or Login: member.healthiestyou.com
Referral Required
No
No
No
No
Office Visits Consultations for Illness / Injury
Deductible & Coinsurance
$40 copay
$40 copay
$25 copay
Specialist Visits
Deductible & Coinsurance
$65 copay
$55 copay
$40 copay
Inpatient Hospital
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Deductible
Outpatient Surgery
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Deductible
Emergency Room
Deductible & Coinsurance
$350 copay
$250 copay
$350 copay
Urgent Care
Deductible & Coinsurance
$100 copay
$100 copay
$100 copay
OUTPATIENT DIAGNOSTIC SERVICES
Lab Services (Freestanding Lab)
Deductible & Coinsurance
Covered 100%
Covered 100%
Covered 100%
X-Ray Services (Freestanding Lab)
Deductible & Coinsurance
Covered 100%
Covered 100%
Covered 100%
Complex Diagnostic
Deductible & Coinsurance
$300 copay
$300 copay
$300 copay
PRESCRIPTIONS Retail (30 day supply)
Deductible & Coinsurance
$15 / $45 / $90 / 25%
$10 / $40 / $70 / 25%
$10 / $30 / $50 / 25%
Mail Order (90 day supply)
Deductible & Coinsurance
2.5 x retail
2.5 x retail
2.5 x retail
OUT-OF-NETWORK Deductible (Individual / Family)
$12,000 / $24,000
$7,500 / $15,000
$1,500 / $3,000
Coinsurance
50% / 50%
50% / 50%
70% / 30%
Not Available In-Network Benefits Only
Maximum Out-of-Pocket (Individual / Family)
$18,000 / $36,000
$18,000 / $36,000
$19,500 / $39,000
Lifetime Maximum
Unlimited
Unlimited
Unlimited
3
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