High-Deductible Health Plans MEDICAL PLAN BENEFITS
HSA PLAN
In-Network
Out-of-Network
$2,000 $4,000
$4,000 $8,000
20% after deductible
50% after deductible
$4,000 $8,000
$8,000 $16,000
Physician Services • Primary Physician Visit • Specialist Visit • Virtual Visit • Preventive Care
20% after deductible 20% after deductible Up to $50 No charge
50% after deductible 50% after deductible Not covered Not covered
Inpatient Hospital Care
20% after deductible
50% after deductible
Outpatient Surgery
20% after deductible
50% after deductible
Emergency Room Care
20% after deductible
50% after deductible
Urgent Care Center
20% after deductible
50% after deductible
Deductible • Individual • Family Coinsurance (you pay) Out-of-Pocket Maximum (includes deductible) • Individual • Family
Prescription Drugs – Retail Pharmacy (up to a 31-day supply) • Preventive Medications • Tier 1 – Your Lowest Cost Option • Tier 2 – Your Mid-Range Cost Option • Tier 3 – Your Highest Cost Option Prescription Drugs – Mail-Order (up to a 90-day supply) • Preventive Medications • Tier 1 – Your Lowest Cost Option • Tier 2 – Your Mid-Range Cost Option • Tier 3 – Your Highest Cost Option
Once you meet the deductible, the copays below apply: No charge $10 copay $50 copay $75 copay
You pay the in-network copay plus all charges above UHC’s allowed amount.
Once you meet the deductible, the copays below apply Not covered
No charge $25 copay $125 copay $187.50 copay
You must pay the full cost of your medical and non-preventive prescription drug expenses until you meet the annual deductible. The coinsurance and prescription drug copays shown apply only after the deductible has been paid.
Tips to Save Money PREVENTIVE/WELLNESS EXAMS ARE COVERED AT 100% • In-network preventive care is equal to one physical exam per year per enrolled member.
PRESCRIPTION DRUGS • Ask your doctor if there is a generic version of the medication you’re taking. • Take advantage of the Generic Prescription Savings Programs at major retailers. • Ask about free samples from your doctor and/or manufacturer rebates.
HIGH COST SCANS, X-RAYS & TESTS • MRI, PET scans, CT scans, etc. are nearly 2/3 less costly at free-standing, in-network imaging centers than at hospitals. • Finding an in-network, free-standing imaging center can save you money.
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