Page 3 - 2015 NVW Open Enrollment Guide

New Vision Wilderness Therapy

Your Medical Plan Options for 2015

UnitedHealthcare UnitedHealthcare
Buy-Up Plan Basic Plan
1/1/2015 1/1/2015
POS Out-of-Network POS Out-of-Network
Lifetime maximum Unlimited Unlimited Unlimited Unlimited
Calendar Year Deductible
Individual $1,500 $4,500 $5,000 $10,000
Family $3,000 $9,000 $10,000 $20,000
Out-of-Pocket Maximum Includes Deductible and Non-Rx Copays Includes Deductible and Non-Rx Copays
Individual $4,000 $8,000 $6,250 $12,500
Family $8,000 $16,000 $12,500 $25,000
Physician Ofice Visits
Primary Care $25 copay 70% after deductible $25 copay 70% after deductible
Specialist $50 copay 70% after deductible $70 copay 70% after deductible
Urgent Care $100 copay 70% after deductible $100 copay 70% after deductible
Wellness/Preventive
Annual Maximum Unlimited Unlimited Unlimited Unlimited
Immunizations 100% 70% after deductible 100% 70% after deductible
Physical Exams 100% 70% after deductible 100% 70% after deductible
Well-Woman and 100% 70% after deductible 100% 70% after deductible
Well-Man Exams
Hospital Services
Inpatient/Outpatient 100% after deductible 70% after deductible 100% after deductible 70% after deductible
Emergency Room $300 copay; 100% $300 copay; 100% $300 copay; 100% $300 copay; 100%
Lab and X-Ray
Physician’s Ofice 100% no deductible 70% after deductible 100% no deductible 70% after deductible
Outpatient-Non Major 100% no deductible 70% after deductible 100% no deductible 70% after deductible
Outpatient-Major (CT, PET, MRI, 100% after deductible 70% after deductible 100% after deductible 70% after deductible
MRA)

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