Page 8 - 2022 Insurity OE Guide FINAL

Did You Know?

Covered dependents may
remain on your plan until the
UnitedHealthcare end of the calendar year in
which they turn age 26.
Medical Plan Highlights

UnitedHealthcare Medical Plans Choice Plus Network –

Group Number #755681

HDHP/HSA Plan 1 HDHP/HSA Plan 2 POS Plan 3

IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK
Calendar Year Deductible
Individual / Family $3,000 / $6,000 $4,000 / $8,000 $2,000 / $4,000 $4,000 / $8,000 $1,000 / $3,000 $4,000 / $8,000
Coinsurance (after reaching deductible)

80% UHC / 60% UHC / 80% UHC / 60% UHC / 70% UHC / 60% UHC /
Coinsurance
20% Member 40% Member 20% Member 40% Member 30% Member 40% Member
Calendar Year Out-of-Pocket Maximum (Includes Deductible)
$10,000 / $10,000 / $10,000 /
Individual / Family $4,500 / $6,850 $4,000 / $6,850 $3,000 / $6,000
$20,000 $20,000 $20,000
Coinsurance

Preventive Care 60% UHC / 60% UHC / 60% UHC /
(Including TeleHealth with your Covered 100% 40% Member Covered 100% 40% Member Covered 100% 40% Member
own provider)
Primary Care Office Visit 80% UHC / 60% UHC / 80% UHC / 60% UHC / 70% UHC / 60% UHC /
(Including TeleHealth with your 20% Member 40% Member 20% Member 40% Member 30% Member 40% Member
own provider)
Virtual Visit
(Teladoc, Doctor on Demand $49 N/A $49 N/A $49 N/A
or Amwell)
Specialist Office Visit 80% UHC / 60% UHC / 80% UHC / 60% UHC / 70% UHC / 60% UHC /
(Including TeleHealth with your 20% Member 40% Member 20% Member 40% Member 30% Member 40% Member
own provider)
80% UHC / 60% UHC / 80% UHC / 60% UHC / 70% UHC / 60% UHC /
Hospital Inpatient
20% Member 40% Member 20% Member 40% Member 30% Member 40% Member
80% UHC / 60% UHC / 80% UHC / 60% UHC / 70% UHC / 60% UHC /
Hospital Outpatient
20% Member 40% Member 20% Member 40% Member 30% Member 40% Member
Radiology and 80% UHC / 60% UHC / 80% UHC / 60% UHC / 70% UHC / 60% UHC /
Advanced Imaging 20% Member 40% Member 20% Member 40% Member 30% Member 40% Member
80% UHC / 80% UHC / 70% UHC /
Emergency Room* N/A N/A N/A
20% Member 20% Member 30% Member
80% UHC / 60% UHC / 80% UHC / 60% UHC / 70% UHC / 60% UHC /
Urgent Care
20% Member 40% Member 20% Member 40% Member 30% Member 40% Member
*If you are in an out-of-network area and have an emergency room visit, your service will be processed as an in-network claim.
In-network and out-of-network deductibles and out-of-pocket maximums do not cross accumulate.

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