Page 7 - DataMax Benefits Enrollments Guide

Medical & Prescription Drug Plan

Policy# 05W6575 Effective 10/01/2017

United Healthcare – Core HSA Plan

ALYL- AX
Benefit Highlights

In-Network Member Pays

Primary Care Physician Visit Deductible then 30%

Specialist Office Visit Deductible then 30%
Virtual Visit Deductible then 30%
Preventive Care Visits 0% (100% covered by the plan)

Emergency Room Services (waived if admitted) Deductible then 30%
Urgent Care Center Deductible then 30%
Inpatient Hospital & Professional Charges Deductible then 30%

Outpatient Facility & Physician Charges Deductible then 30%
Prescription Medication:

Tier 1 Deductible then 30%

Tier 2 Deductible then 30%

Tier 3 Deductible then 30%

Individual Annual Deductible $5,250
Individual Annual Coinsurance Maximum $1,300
Individual Annual Out-of-Pocket Maximum $6,550

Family Annual Deductible $10,500
Family Annual Coinsurance Maximum $2,600

Family Annual Out-of-Pocket Maximum $13,100

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