Page 10 - Omega Benefits Guide
P. 10
Medical & Prescription Drug Plan
Core Plan
UNITED HEALTHCARE-CORE PLAN
United Healthcare
Choice Plus HSA
AJ-OM w/Rx 2V
Benefit Highlights
In-Network Member Pays
Primary Care Physician Copay Deductible then 20%
Specialist Office Visit Copay Deductible then 20%
Preventive Care Visits 0% (Plan covers 100%)
Emergency Room Services (waived if admitted) Deductible then 20%
Urgent Care Center Copay Deductible then 20%
Inpatient Hospital & Professional Charges Deductible then 20%
Outpatient Facility & Physician Charges Deductible then 20%
Prescription Medication Copay:
Tier 1 Deductible then $10
Tier 2 Deductible then $35
Tier 3 Deductible then $60
Tier 4 N/A
Mail Order 2.5 times retail copays
Individual Annual Deductible $ 4,000
Individual Annual Coinsurance Maximum $ 2,500
Individual Annual Out-of-Pocket Maximum $ 6,500
Family Annual Deductible $ 8,000
Family Annual Coinsurance Maximum $ 5,000
Family Annual Out-of-Pocket Maximum $ 13,000
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