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 (Individual/Family)	$500/$1,500	Not covered
Member Coinsurance	20%	Not covered
Out-of-Pocket Max (Individual/Family)	$2,000/$6,000	Not covered
Physician Visits
Primary Care	$20 Copay	Not covered
Routine Preventive Care	Covered at 100%	Not covered
Specialist	$60 Copay	Not covered
Hospital Services
Physician Services	Deductible + 20%	Not covered
Inpatient Hospitalization	Deductible + 20%	Not covered
Outpatient Surgery	Deductible + 20%	Not covered
Outpatient Diagnostics: Outpatient Labs	Designated Network: Deductible + 20% In-Network: Deductible + 30%	Not covered
Outpatient Diagnostics: XRay and Other	Deductible + 20%	Not covered
Outpatient Diagnostics: Major Diagnostics	Designated Network: Deductible + 20% In-Network: Deductible + 30%	Not covered
Urgent Care Services	$50 Copay	Not covered
Emergency Room Visit	Deductible + 20%	Deductible + 20%
Retail Prescriptions
Tier 1-Generic/Generic Specialty	$10	Not covered
Tier 2-Preferred	$40	Not covered
Tier 3-Non-Preferred/Preferred Specialty	$105	Not covered
Tier 4-Non-Preferred Specialty	$250	Not covered
Specialty Prescriptions
Tier 1-Generic	$10	Not covered
Tier 2-Preferred	$40	Not covered
Tier 3-Non-Preferred	$105	Not covered
Tier 4-Specialty	$250	Not covered
Mail Order Prescriptions
Tier 1-Generic	$25	Not covered
Tier 2-Preferred	$100	Not covered
Tier 3-Non-Preferred	$262.50	Not covered
Tier 4-Specialty	$625	Not covered

Downloads

Summary of Benefits

	In-Network	Out-of-Network
Deductible (Individual/Family)	$1,500/$3,000	$5,000/$10,000
Member Coinsurance	20%	50%
Out-of-Pocket Max (Individual/Family)	$8,000/$16,000	$10,000/$20,000
Physician Visits
Primary Care	$35 Copay per visit for the first 4 visits in a year; then 20% for all other visits in the same year.*	Deductible + 50%
Routine Preventive Care	Covered at 100%	Deductible + 50%
Specialist	Designated Network: $35 Copay per visit for the first 4 visits in a year; then 20% for all other visits in the same year.* In Network: $70 Copay per visit for the first 4 visits in a year; then 20% for all other visits in the same year.*	Deductible + 50%
Hospital Services
Physician Services	Deductible + 20%	Deductible + 50%
Inpatient Hospitalization	Deductible + 20%	Deductible + 50%
Outpatient Surgery	Deductible + 20%	Deductible + 50%
Outpatient Diagnostics: Outpatient Labs	Designated Network: Deductible + 20% In-Network: Deductible + 30%	Deductible + 50%
Outpatient Diagnostics: XRay and Other	Deductible + 20%	Deductible + 50%
Outpatient Diagnostics: Major Diagnostics	Designated Network: Deductible + 20% In-Network: Deductible + 30%
Urgent Care Services	In-Network: $50 Copay per visit for the first 4 visits in a year; then 20% for all other visits in the same year.*	Deductible + 50%
Emergency Room Visit	Deductible + 20%	Deductible + 20%
Retail Prescriptions
Tier 1-Generic/Generic Specialty	$10	$10
Tier 2-Preferred	$40	$40
Tier 3-Non-Preferred/Preferred Specialty	$105	$105
Tier 4-Non-Preferred Specialty	$250	$250
Specialty Prescriptions
Tier 1-Generic	$10	$10
Tier 2-Preferred	$40	$40
Tier 3-Non-Preferred	$105	$105
Tier 4-Specialty	$250	$250
Mail Order Prescriptions
Tier 1-Generic	$25	$25
Tier 2-Preferred	$100	$100
Tier 3-Non-Preferred	$262.50	$262.50
Tier 4-Specialty	$625	$625

Downloads

Summary of Benefits

Provided By

United Healthcare

Provider Website

https://www.myuhc.com

Customer Service

866.414.1959

Resources

Frequently Asked Questions