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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.
UnitedHealthCare
HMO Advantage HMO Platinum 20-40-20% (CE-NV)

DEDUCTIBLE NONE
Annual Out-of-Pocket Maximum $3,500/Individual & $7,000/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
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 $10 $20

Brand – Formulary $35 $70
Brand – Non-Formulary $70 $140

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