Page 8 - DataMax Benefits Enrollments Guide
P. 8
Medical & Prescription Drug Plan
Policy# 05W6575 Effective 10/01/2017
United Healthcare – Buy Up Plan
ALYM-AA
Benefit Highlights
In-Network Member Pays
Primary Care Physician Copay $50
Specialist Office Visit Copay $150
Virtual Visit Copay* $15
Preventive Care Visits 0% (100% covered by the plan)
Emergency Room Services (waived if admitted) Deductible then 30%
Urgent Care Center Copay $100
Inpatient Hospital & Professional Charges Deductible then 30%
Outpatient Facility & Physician Charges Deductible then 30%
Prescription Medication Copay:
Tier 1 $15
Tier 2 $50 / $125
Tier 3 $75 / $250
Individual Annual Deductible $2,000
Individual Annual Coinsurance Maximum $5,000
Individual Annual Out-of-Pocket Maximum $7,000
Family Annual Deductible $4,000
Family Annual Coinsurance Maximum $10,000
Family Annual Out-of-Pocket Maximum $14,000
*Network Benefits are available only when services are delivered through a Desginated Virtual Visit Network Provider. Find a
Designated Virtual Visit Network Provider Group at myuhc.com or by calling Customer Care at the telephone number on your ID
card.
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