United Healthcare
UNITED HEALTHCARE STANDARD POS
UNITED HEALTHCARE AMAZING POS
UNITED HEALTHCARE OMG! POS
Out of Network
Out of Network
Out of Network
In Network
In Network
In Network
Calendar Year Deductible (Single/Family)
$2,000/$4,000 $4,000/$8,000 $500/$1,000 $1,000/$2,000 $250/$500 $1,000/$2,000
Calendar Year Out-of-Pocket Maximum (Single/Family)
$5,000/$10,00 0
$10,000/$20,00 0
$3,500/$7,000 $7,000/$14,000 $2,500/$5,000 $5,000/$10,000
Preventive Services
No Charge Not Covered No Charge Not Covered No Charge Not Covered
$40/$50 copay (deductible waived)
$25/$50 copay (deductible waived)
$20/$40 copay (deductible waived)
40%after deductible
40%after deductible
20%after deductible
Office Visits (Primary/Specialist)
Telemedicine
$40 copay
$25 copay
$20 copay
X-Ray 40% after deductible, Lab Not covered
X-Ray 40% after deductible, Lab Not covered
X-ray 20% after deductible, Lab Not covered
Lab & X-ray
No Charge
No Charge
No Charge
Complex Radiology (includes CT, PET and MRI)
20% after deductible
40% after deductible
20% after deductible
40% after deductible
0% after deductible
20% after deductible
Inpatient Hospital Services (includes Maternity)
20% after deductible
40% after deductible
20% after deductible
40% after deductible
20% after deductible
$500 copay
20% after deductible
40% after deductible 40% after deductible
20% after deductible
40% after deductible 40% after deductible
0% after deductible
20% after deductible 20% after deductible
Outpatient Surgery
Urgent Care
$50 copay
$50 copay
$50 copay
Emergency Room (Co-pay waived if admitted)
20% after deductible
$200 copay per visit
$150 copay
Ambulance
20% after deductible
$200 copay per visit
$150 copay
Calendar Year Drug Deductible
No Deductible
No Deductible
No Deductible
$15/$35/$50 + the Difference in Cost
$15/$35/$50 + the Difference in Cost
$15/$35/$50 + the Difference in Cost
Retail Prescription (up to a 31-day supply) (tier1/tier2/tier3)
$15/$35/$50
$15/$35/$50
$15/$35/$50
$37.50/$87.50/ $125
Mail-Order Prescription (up to a 90-day supply) (tier1/tier2/tier)
$37.50/$87.50/ $125
$37.50/$87.50/ $125
Not Covered
Not Covered
Not Covered
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