Page 8 - BOC 2021 Benefits Booklet

MEDICAL INSURANCE

UnitedHealthCare PPO
Group Number: 913337
Plan: Select Plus PPO BPAP RX 743

Member Pays
Benefits
PPO Non PPO

Individual/Family Deductible $1,000/$2,000 $2,000/$4,000
Individual/Family Out of Pocket Max $5,000/$10,000 $10,000/$20,000
$35 copay
Primary Care Physician Office Visits (deductible waived) 40%
$35 copay
Specialists Office Visits (deductible waived) 40%
Lab & X-ray – Basic 0% 40%
Lab & X-ray – Complex 20% 40%
(i.e. MRI, MRA, PET, CT)
Emergency Room: $100 copay+ 20% $100 copay+ 20%
(copay waived if admitted) (copay waived if admitted)
Inpatient Hospital – Room/Board $100 copay+ 20% $100 copay+ 40%
(after deductible)
(after deductible)
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: $35 copay 40%

(Limited to 20 visits per calendar year; additional visits may be authorized)

Prescription Drugs Participating Pharmacy

Generic: $10 copay $10 copay
Brand Name $30 copay $30 copay

Non Formulary: $50 copay $50 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

8