United HealthCare – Medical Coverage Plan Type
Choice Plus PPO
Physician Office Visit
$30 Copayment (In Network) / 50% of Eligible Expenses (Out of Network)
Specialist Office Visit
$50 Copayment (In Network) / 50% of Eligible Expenses (Out of Network)
Lab, X-Rays and Diagnostic Test
For Preventive Diagnostic Services - No Co-pay/all others 80%
Inpatient Hospitalization
80% of eligible expenses after deductible (In Network)/50% of Eligible Expenses (Out of Network)
Outpatient Surgery/Services
80% of eligible expenses after deductible (In Network)/50% of Eligible Expenses (Out of Network)
RX (based on 31 day supply)
$10 Tier 1/$30 Tier 2/$50 Tier 3
o $1,200 In-Network Annual Deductible per person per calendar year, Annual Deductible
not to exceed $2,400 for all covered person in a family.
o $2,400 Out of Network Annual Deductible per person per calendar year, not to exceed $9,200 for all covered person in a family.
o $4,900 In-Network out of pocket maximum per covered person per Out-of-pocket Maximum
calendar year, not to exceed $9,800 for all covered persons in a family o Unlimited out of pocket maximum benefit for Out of Network. (Not including annual deductibles and some co-pays).
Emergency Care
$250 Copayment
Urgent Care
$60 Copayment (In Network) / 50% of Eligible Expenses (Out of Network)
Routine Vision Care
$30 per visit (In Network) / 50% of Eligible Expenses (Out of Network)
(based on annual visit)
Outpatient Mental Health/Substance Abuse Visits
$50 per visit (In Network) / 50% of Eligible Expenses (Out of Network)
United Health Care - Dental Plan Type
Option PPO
Physician Office Visit
100% (In Network) No deductible
Basic Services (extractions, oral surgery, anesthesia, resin or amalgam fillings)
80% of eligible expenses after deductible
Major Services (dental implants, bridges, crowns, dentures)
50% of eligible expenses after deductible
Orthodontics
50% of eligible expenses after deductible (up to 19 years of age) o
$50 per calendar year, per individual, $150 per calendar year per family. Applies to basic, major and orthodontic dental expenses.
o
There is no deductible for preventative care.
Annual Deductible Maximum
$1500 maximum per person per calendar year.
United Health Care - Vision Plan Type
PPO (Spectera)
Comprehensive Exam
$10 Copayment (In Network) / Varies–claim reimbursement required (Out of Network)
Materials
$25 co-pay for materials (i.e. eyeglasses or contacts in lieu of eyeglasses).
Frequency
Exams – Every 12 months Lenses – Every 12 months Frames – Every 24 months Contacts – Every 12 months
Frame Benefit Laser Vision
Private Practice Provider - $120-150 allowance Retail Chain Provider - $130 allowance Discounted laser vision correction providers available.