Page 7 - BOC 2021 Benefits Booklet

MEDICAL INSURANCE

UnitedHealthCare HSA
Group Number: 913337
Plan: Select Plus H.S.A. BPDN RX0B

Member Pays
Benefits
PPO Non PPO

Individual/Family Deductible $2,800/$5,600 $4,700/$9,400
All services with the exception of specific Preventive Care are
subject to the deductible. (Embedded)
Individual/Family Out of Pocket Max $4,700/9,400 $9,400/$18,800
Primary Care Physician Office Visits 20% 40%
Specialists Office Visits 20% 40%
Lab & X-ray – Basic 20% 40%
Lab & X-ray – Complex 20% 40%
(i.e. MRI, MRA, PET, CT)
Emergency Room: 20% 20%

Inpatient Hospital – Room/Board 20% 40%

Inpatient Professional Services 20% 40%
Outpatient Surgery: 20% 40%
(Freestanding Surgical Facility)
Maternity – Office Visit copay: 0% 40%

Maternity – Hospital: See Hospitalization
Well Baby Care: No Charge 40%
Chiropractic Care: 20% 40%

(Limited to 20 visits per calendar year)

Prescription Drugs Participating Pharmacy

Drug Deductible All Drugs Subject to Medical Deductible
Generic: $15 copay $15 copay
Brand Name $40 copay $40 copay
Non Formulary: $60 copay $60 copay

Questions?

Member Services: 866-414-1959
Website: www.myuhc.com

* When filling Prescriptions at a Non-PPO Pharmacy, you are responsible for any difference between the
Non-Network Pharmacy charges and the amount UHC would have paid for the same prescription drug
product dispensed by a Network Pharmacy

7