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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.


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