Page 7 - MCU Benefits Guide
P. 7
Medical & Prescription Drug Plan
United Healthcare
AR-3Y (Balanced) RX 2V
Benefit Highlights
In-Network Member Pays
Primary Care Physician Copay $ 35
Specialist Office Visit Copay $ 70
Virtual Visit $ 10
Preventive Care Visits 0% (Plan covers 100%)
Emergency Room Services (waived if admitted) $350
Urgent Care Center Copay $75
Inpatient Hospital & Professional Charges Deductible then 30%
Outpatient Facility & Physician Charges Deductible then 30%
Prescription Medication Copay: Mail Order 90-day supply is 2.5x copay
Tier 1 $ 10
Tier 2 $ 35
Tier 3 $ 60
Individual Annual Deductible $ 5,000
Individual Annual Coinsurance Maximum $ 2,000
Individual Annual Out-of-Pocket Maximum $ 7,000
Family Annual Deductible $ 10,000
Family Annual Coinsurance Maximum $ 4,000
Family Annual Out-of-Pocket Maximum $ 14,000
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