MEDICAL INSURANCE
Jagged Peak offers four medical plans through UnitedHealthcare (UHC). To find participating providers go to www.myuhc.com and click on “Find a Doctor”, then follow the prompts to complete the search.
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
Plan 1 UHC Choice AQP2
Plan 2 UHC Choice AQOI
Plan 3 UHC Choice AQPV
Plan 4 UHC Choice Plus AQNL
IN-NETWORK: Calendar Year Deductible (Individual/Family) Maximum Out-of-Pocket (Individual/Family) Out-of Pocket Max Includes Routine Preventive Services Preventive Office Visits CO-PAYS Referral Required Office Visits/Consultations for Illness/Injury Coinsurance
$5,000 / $10,000
$2,500 / $5,000
$1,000 / $2,000
$500 / $1,000
$6,500 / $13,000
$6,500 / $13,000
$6,500 / $13,000
$6,500 / $13,000
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
50%
80%
100%
100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
No
No
No
No
$40 Copay $65 Copay
$40 Copay $55 Copay
$25 Copay $40 Copay
$25 Copay $40 Copay
Specialist Visits Inpatient Hospital
Covered 50% after deductible Covered 50% after deductible Covered 100% after $350 Copay Covered 100% after $100 Copay
Covered 80% after deductible Covered 80% after deductible Covered 100% after $250 Copay Covered 100% after $100 Copay
Covered 100% after deductible Covered 100% after deductible Covered 100% after $350 Copay Covered 100% after $100 Copay
Covered 100% after deductible Covered 100% after deductible Covered 100% after $350 Copay Covered 100% after $100 Copay
Outpatient Surgery
Emergency Room
Urgent Care
Outpatient Diagnostic Services Lab Services
Covered 100% Covered 100%
Covered 100% Covered 100%
Covered 100% Covered 100%
Covered 100% Covered 100%
X-Ray Services
Covered 100% after $300 Copay
Covered 100% after $300 Copay
Covered 100% after $300 Copay
Covered 100% after $300 Copay
Complex Diagnostic Prescriptions Retail (30 day supply)
$10 / $30 / $70
$10 / $30 / $70
$10 / $30 / $50
$10 / $30 / $50
Mail Order (90 day supply)
2.5 X retail
2.5 X retail
2.5 X retail
2.5 x retail
OUT-OF-NETWORK:
Deductible (Individual / Family)
$1,500 / $3,000 $19,500 / $39,000
In-Network Only
In-Network Only
In-Network Only
Maximum Out-of-Pocket
Coinsurance
70%
See bi-weekly costs on page 7
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