Medical Benefits
The plan being offered through UHC provides benefits for medical services received through in-network physicians and hospitals and, on a lower benefit level, out-of-network physicians and hospitals. This allows you the choice of seeking care from any doctor you choose. Your out-of-pocket costs will be significantly lower when you use doctors and hospitals listed in the online provider directory. If you choose not to utilize an in-network provider, your benefits will be paid at the lower out-of-network level. To access membership information, please visit myuhc.com.
In-Network |
Out-of-Network |
|
|---|---|---|
Deductible |
$1,000/$2,000 |
$5,000/$10,000 |
Member Coinsurance |
80% |
50% |
Out-of-Pocket Max |
$7,450/$14,900 |
$10,000/$20,000 |
Primary Care Visit |
$35 copay for 1st 4 Visits |
Deductible + 50% |
Specialist Visit |
$70 copay for 1st 4 Visits |
Deductible + 50% |
Routine Preventive Care |
No charge |
Deductible + 50% |
Urgent Care |
$50 for 1st 4 Vists then |
Deductible + 50% |
Emergency Room |
$500 Copay: Deductible + 20% |
$500 Copay; Deductible + 20% |
Lab, X-Ray & Out Patient Basic Diag. |
Designated Network: Deductible + 20% |
Deductible + 50% |
Major Diagnostics & Imaging |
Deductible + 20% |
Deductible + 50% |
Physician Services |
Deductible + 20% |
Deductible + 50% |
Inpatient Hospital |
Deductible + 20% |
Deductible + 50% |
Outpatient Surgery Fee |
Deductible + 20% |
Deductible + 50% |
Retail Prescription Drugs |
In-Network |
Out-of-Network |
|---|---|---|
Tier 1 |
$10 Copay |
$10 Copay |
Tier 2 |
$40 Copay |
$40 Copay |
Tier 3 |
$105 Copay |
$105 Copay |
Tier 4 |
$250 Copay |
$250 Copay |
Tier 5 |
$500 Copay |
$500 Copay |
Monthly Rates by Age |
|
|---|---|
<15 |
$403.23 |
15 |
439.07 |
16 |
$452.78 |
17 |
$466.48 |
18 |
$481.24 |
19 |
$496.00 |
20 |
$511.29 |
21 |
$527.10 |
22 |
$527.10 |
23 |
$527.10 |
24 |
$527.10 |
25 |
$529.21 |
26 |
$539.75 |
27 |
$552.40 |
28 |
$572.96 |
29 |
$589.82 |
30 |
$598.26 |
31 |
$610.91 |
32 |
$623.56 |
33 |
$631.47 |
34 |
$639.90 |
35 |
$644.12 |
36 |
$648.30 |
37 |
$652.55 |
38 |
$656.77 |
39 |
$665.20 |
40 |
$673.63 |
41 |
$686.28 |
42 |
$698.41 |
43 |
$715.27 |
44 |
$736.36 |
45 |
$761.13 |
46 |
$790.65 |
47 |
$823.86 |
48 |
$861.81 |
49 |
$899.23 |
50 |
$941.40 |
51 |
$983.04 |
52 |
$1,028.90 |
53 |
$1,075.28 |
54 |
$1,125.36 |
55 |
$1,175.43 |
56 |
$1,229.72 |
57 |
$1,284.54 |
58 |
$1,343.05 |
59 |
$1,372.04 |
60 |
$1,430.55 |
61 |
$1,481.15 |
62 |
$1,514.36 |
63 |
$1,556.00 |
64+ |
$1,581.30 |