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Medical Plan Highlights
United Healthcare Plans
IN NETWORK
UHC "Platinum" POS (OA) BAFJ National Plan
UHC "Gold" POS (OA) BAK4 National Plan
UHC "Silver" POS (OA) BAEO National Plan
UHC "Bronze" POS (OA) BADO - HSA National Plan
Doctor Co-Pay (PCP/Specialist)
Deductible (Individual/Family) Coinsurance (Insurance/Member) Inpatient Hospitalization Outpatient Surgery (PCP/Specialist)
Physical Therapy Chiropractic
Lab / X-Ray / Advanced Diagnostics Urgent Care
Emergency Room
Out-of-Pocket Maximum (Ind/Fam)
$15/$30
$30/$60
Ded + Coins
Ded + Coins $5,000/$10,000 90%/10% Ded + Coins Ded + Coins
Ded + Coins/20 visits combined w/ PT & OT
Ded + Coins/20 visits max
Ded + Coins Ded + Coins Ded + Coins $6,650/$13,300
$0/$0 100%/0%
$1000/$3000 80%/20%
$3000/$6000 80%/20%
$0 Copay
$0 Copay
$15 Copay/20 visits max (PT & OT com-
bined)
$15 Copay/20 visits
max
Ded + Coins Ded + Coins
$30 Copay/20 visits max
$30 Copay/20 visits max
Ded + Coins Ded + Coins
Ded + Coins/20 visits max
Ded + Coins/20 visits max
$0/$0/$150 Copay $75 Copay $250 Copay
Ded + Coins $75 Copay $300 Copay
Ded + Coins Ded + Coins Ded + Coins
$3000/$6000
$3000/$6000
$6,000/$12,000
OUT-OF-NETWORK
Deductible (Individual/Family) Coinsurance (Insurance/Member) Out-of-Pocket Maximum (Ind/Fam)
$1000/$2000 80%/20% $6000/$12,000
$2000/$4000 60%/40% $6000/$12,000
$6,000/$12,000 60%/40% $12,000/$24,000
$10,000/$20,000 70%/30% $15,000/$30,000
COVERED PRESCRIPTIONS
Deductible
Retail (Tier 1/Tier 2/Tier 3) Mail-Order (Tier 1/Tier2/Tier 3) Tier 4 (Specialty)
$0 $10/$35/$60 $25/$87.5/$150
$0 $10/$35/$60 $25/$87.5/$150
$0 $10/$30/$50 $25/$75/$125
Combined w/Med $10/$35/$60 $25/$87.5/$150
varies; see Rx Summary
varies; see Rx Summary
varies; see Rx Summary
varies; see Rx Summary
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