Traditional PPO Plans MEDICAL PLAN BENEFITS
BASE PPO PLAN
BUY-UP PPO PLAN
In-Network
Out-of-Network
In-Network
Out-of-Network
$4,000 $12,000
$8,000 $24,000
$1,000 $3,000
$2,000 $6,000
25%
50%
20%
50%
$8,000 $16,000
$16,000 $32,000
$3,500 $7,000
$7,000 $14,000
• Primary Physician Visit
$30 copay
50% after deductible
$30 copay
50% after deductible
• Specialist Visit
$100 copay
50% after deductible
$100 copay
50% after deductible
• Premium Designated Providers
$30 copay
50% after deductible
$30 copay
50% after deductible
• Virtual Visit
$0 copay
Not covered
$0 copay
Not covered
• Preventive Care
$0 copay
Not covered
$0 copay
Not covered
• Outpatient Mental Health Visit
$0 copay
50% after deductible
$0 copay
50% after deductible
Deductible (does not include copays) • Individual • Family Coinsurance (you pay) Out-of-Pocket Maximum (includes deductible and copays) • Individual • Family Physician Services
Inpatient Hospital Care
25% after deductible
50% after deductible
20% after deductible
50% after deductible
Outpatient Surgery
25% after deductible
50% after deductible
20% after deductible
50% after deductible
Emergency Room Care Urgent Care Center
25% after deductible 25% after deductible
Prescription Drugs – Retail Pharmacy (up to a 31-day supply) • Generic Diabetic • Tier 1 – Your Lowest Cost Option • Tier 2 – Your Mid-Range Cost Option • Tier 3 – Your Highest Cost Option
No charge $20 copay $50 copay $75 copay
50% after deductible You pay the in-network copay plus all charges above UHC’s allowed amount
$200 copay per visit $100 copay
No charge $10 copay $40 copay $60 copay
50% after deductible You pay the in-network copay plus all charges above UHC’s allowed amount.
Prescription Drugs – Mail-Order (up to a 90-day supply) • Tier 1 – Your Lowest Cost Option • Tier 2 – Your Mid-Range Cost Option • Tier 3 – Your Highest Cost Option
Not covered
$50 copay $125 copay $187.50 copay
$25 copay $100 copay $150 copay
Not covered
All prescription drugs on OptumRx’s Prescription drug list are assigned to Tier 1, Tier 2, or Tier 3. Find individualized information on your benefits coverage, determine tier status, check the status of claims, and search for network pharmacies by logging on to www.optumrx.com or calling the Customer Care number on your ID card.
ACCESSING MEDICAL CARE The Emergency Room (ER) is a costly experience if you’re seeking care for an issue that is not a true emergency or a medical issue that could cause death or permanent injury if not treated quickly. There are alternatives to the ER that can offer you quick care at a more affordable cost. The key is finding these alternatives today when you’re happy and healthy. Where you go for care matters. • Primary Care Physician (PCP): care from the doctor who knows you best. For symptoms that aren’t extreme, call and let them know your symptoms require immediate attention. • Virtual Visits: available 24/7 for some health concerns like cough, fever, sinus problems, pink eye, minor rashes and more. You can virtually visit a board-certified doctor from the comfort of your home. • Convenient Care Clinics: when you do not have a primary doctor or cannot get an appointment. Useful for fever, sore throat/strep, coughs/congestion, sports physicals, etc. • Urgent Care (UC): less costly than the ER; can treat sprains, minor breaks, mild asthma, minor infections, rashes, small cuts, burns, etc. 6
