Page 12 - Eden Housing 2022 Benefit Guide

UHC Medical Plan Comparison

UHC HMO UHC PPO Plan
Plan Features (Canopy Plan)
In-Network In-Network Out-of-Network
Calendar Year
1
Deductible None $250 / $500 $1,000 / $2,000
Individual/Family
Calendar Year
Out-of-Pocket $1,500 / $3,000 $2,500 / $5,000 $7,500 / $15,000
2
Maximum
Individual/Family
You pay: You pay: You pay:
Preventive Care Visit Covered in full Covered in full Not Covered
Primary Care Visit $20 copay $15 copay 50% after deductible
Specialist Visit $40 copay $30 copay 50% after deductible
Lab & X-ray $20 copay 20% after deductible 50% after deductible
Emergency Room
(copay waived if $250 copay 20% after deductible 20% after deductible
admitted)
Urgent Care $20 copay $50 copay 50% after deductible
Outpatient Services $40 copay $15 copay 50% after deductible
Inpatient Services No Charge 20% after deductible 50% after deductible

$15 copay 50% after deductible
Chiropractic $15 copay 24 visits per year 24 visits per year

20 combined visits per
Acupuncture year Not Covered Not Covered

Prescription Drugs
Tier 1 (30-day) $10 copay $10 copay $10 copay
Tier 2 (30-day) $35 copay $35 copay $35 copay
Tier 3 (30-day) $60 copay $60 copay $60 copay
Tier 1 (90-day) $25 copay $25 copay Not Covered

Tier 2 (90 -day) $87.50 copay $87.50 copay Not Covered
Tier 3 (90 -day) $150 copay $150 copay Not Covered

This chart provides a brief overview of benefits and coverage. Refer to the detailed summary plan documents for
questions about a specific procedure, service, or provider. In the event of a conflict, the official plan documents prevail.

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