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Medical Plans At-A-Glance
HMO 1: UnitedHealthCare Advantage HMO Platinum
Medical & Prescription Drug Coverage
Please refer to your Summary Plan Description for specific details. [HMO 20]
HMO UnitedHealthCare
Advantage HMO Platinum
DEDUCTIBLE NONE
Annual Out-of-Pocket Maximum $2,500/Individual & $5,000/Family
Lifetime Maximum Unlimited
OUTPATIENT SERVICES
Office Visit $20 per Visit for PCP
$40 per Visit for Specialist
Preventive Care No Charge
Well-Baby & Well Child Care No Charge
Diagnostic Lab & X-Ray Lab: $15, X-Ray: $15
Complex Imaging Services (CT, MRI,
etc.) $100 copay per procedure
Durable Medical Equipment $50 copay per item
Outpatient Surgery – Hospital 30% co-insurance
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 30% co-insurance
Ambulance $100 copay/trip
Retail Pharmacy Mail-Order
PRESCRIPTION DRUGS (up to 30 days) (up to 90 days)
Generic $15 $30
Brand – Formulary $35 $70
Brand – Non-Formulary $50 $100
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