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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 UnitedHealthCare
Advantage HMO Platinum
DEDUCTIBLE NONE

Annual Out-of-Pocket Maximum $3,000/Individual & $6,000/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: $25, X-Ray: $25

Durable Medical Equipment $50 copay per item
Outpatient Surgery – Hospital 20% co-insurance

MATERNITY CARE SERVICES
Pre-Natal Maternity No Charge
Delivery and Inpatient Services 20% co-insurance

INPATIENT SERVICES

Hospitalization 20% co-insurance
EMERGENCY SERVICES
Emergency Room 20% 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 $70 $140

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