Page 7 - MCU Benefits Enrollments Guide
P. 7
Medical & Prescription Drug Option
Group # 009S2902
UNITED HEALTHCARE
Balanced Choice Plus
AJ-NT w/2V
Benefit Highlights
In-Network Member Pays
Primary Care Physician Copay $30
Specialist Office Visit Copay $60
Virtual Visits $15
Preventive Care Visits 0% (Plan Covers 100%)
Prescription Medication Copay: Tier 1 $10
Tier 2 $35
Tier 3 $60
Emergency Room Services (waived if
$250
admitted)
Urgent Care Center Copay $100
Inpatient Hospital & Professional Charges Ded then 20%
Outpatient Facility & Physician Charges Ded then 20%
Individual Annual Deductible $4,000
Individual Annual Coinsurance Maximum $2,000
Individual Annual Out-of-Pocket Maximum $6,000
Family Annual Deductible $8,000
Family Annual Coinsurance Maximum $4,000
Family Annual Out-of-Pocket Maximum $12,000
This is an overview. Please see benefit highlight/Summary of Benefits Coverage for complete
details.
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