Page 12 - Signs 365 Benefits Booklet

Signs 365 Major Medical Plan Descriptions

United Healthcare’s Beaumont Network

UHC $5,000 HDHP with $3,000 GAP UHC $5,000 HDHP with $5,000 GAP UHC $5,000 COPAY with $5,000 GAP

Service Benefit Service Benefit Service Benefit

$5,000 Single / $5,000 Single / $5,000 Single /
Deductible Deductible Deductible
$10,000 Family $10,000 Family $10,000 Family
Coinsurance 20% Coinsurance 20% Coinsurance 20%

Out of Pocket $6,350 Single / Out of Pocket $6,350 Single / Out of Pocket $6,500 Single /
Maximum $12,700 Family Maximum $12,700 Family Maximum $13,000 Family
Primary Care Visit 20% Coinsurance 20% Coinsurance Primary Care Visit $0
Primary Care Visit
Copay After Deductible After Deductible
Specialist Office
Specialist Office 20% Coinsurance Specialist Office 20% Coinsurance $100
Visit
Visit After Deductible Visit After Deductible
Emergency Room 20% Coinsurance 20% Coinsurance Emergency Room $250
Emergency Room
Copay After Deductible After Deductible
Urgent Care $50
Urgent Care 20% Coinsurance 20% Coinsurance
Urgent Care
Copay After Deductible After Deductible

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