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Medical Plans At-A-Glance
HMO 2: UnitedHealthCare Advantage HMO Gold
Medical & Prescription Drug Coverage
Please refer to your Summary Plan Description for specific details.
HMO UnitedHealthCare
Advantage HMO Gold
DEDUCTIBLE NONE
Annual Out-of-Pocket Maximum $5,500/Individual & $11,000/Family
Lifetime Maximum Unlimited
OUTPATIENT SERVICES
Office Visit $30 per Visit for PCP
$50 per Visit for Specialist
Preventive Care No Charge
Well-Baby & Well Child Care No Charge
Diagnostic Lab & X-Ray Lab: $25, X-Ray: $25
Complex Imaging Services (CT, MRI,
etc) $200 copay per procedure
Durable Medical Equipment $50 copay per item
Outpatient Surgery – Hospital 30% co-ins for facility, 30% co-ins for physician/surgeon fee
MATERNITY CARE SERVICES
Pre-Natal Maternity No Charge
Delivery and Inpatient Services 30% co-insurance
INPATIENT SERVICES
Hospitalization 30% co-insurance
EMERGENCY SERVICES
Emergency Room $300
Ambulance $100
Retail Pharmacy Mail-Order
PRESCRIPTION DRUGS
(up to 30 days) (up to 90 days)
Generic $15 $30
Brand – Formulary $35 $70
Brand – Non-Formulary $70 $140
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