Page 448 - outbind://23/
P. 448
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 $250/Individual & $500/Family
Annual Out-of-Pocket Maximum $6,000/Individual & $12,000/Family
Lifetime Maximum Unlimited
OUTPATIENT SERVICES
Office Visit $30 per Visit for PCP
$60 per Visit for Specialist
Preventive Care No Charge
Well-Baby & Well Child Care No Charge
Diagnostic Lab & X-Ray Lab: $30, X-Ray: $30
Durable Medical Equipment $50 copay per item
Outpatient Surgery – Hospital 20% co-ins for facility, 20% co-ins for physician/surgeon fee after deductible
MATERNITY CARE SERVICES
Pre-Natal Maternity No Charge
Delivery and Inpatient Services 20% co-insurance after deductible
INPATIENT SERVICES
Hospitalization 20% co-insurance after deductible
EMERGENCY SERVICES
Emergency Room $500 Copay after deductible
Ambulance $100 copay/trip Deductible waived
Retail Pharmacy Mail-Order
PRESCRIPTION DRUGS
(up to 30 days) (up to 90 days)
Generic $15 $30
Brand – Formulary $40 after $250 Drug deductible $80 after $250 Drug deductible
Brand – Non-Formulary $80 after $250 Drug deductible $160 after $250 Drug deductible
10
