Page 6 - Teacher Created Materials EE Guide 09-18 - Non CA

Benefits

Medical Insurance

United Healthcare
Plan Name PPO

Network Name United Healthcare Select Plus Non-Network

Health Benefits

Lifetime Maximum Unlimited
Deductible (Annual)
- Individual $750 $1,500
- Family $1,500 $3,000
- Individual Protection Yes Yes
Co-Insurance (You Pay) 20% 40%
Office Visit Copay
- Preventive Care No Charge Not Covered
- Primary Care Physician $35 Copay Deductible, 40%
- Specialist Office Visit $35 Copay Deductible, 40%
- Urgent Care (Med Group) $125 Copay Deductible, 40%
- Urgent Care (Other) $125 Copay Deductible, 40%
Out-of-Pocket Maximum
- Individual $2,500 $5,000
- Family $5,000 $10,000
- Copays Included Yes Yes

Hospitalization
- Inpatient Deductible, 20% Deductible, 40%
- Outpatient Deductible, 20% Deductible, 40%
Lab and X-Ray
- Diagnostic No Charge Deductible, 40%
- Complex Deductible, 20% Deductible, 40%

Emergency Services $250 Copay
Mental Health
- Inpatient Deductible, 20% Deductible, 40%
- Outpatient $35 Copay Deductible, 40%
Pharmacy Benefits
Pharmacy Deductible $0 $0

Retail Pharmacy
- Generic Formulary $15 Copay $15 Copay + Difference
- Brand Name Formulary $35 Copay $35 Copay + Difference
- Non-Formulary $50 Copay $50 Copay + Difference
- Supply Limit 31 Days 31 Days
Mail Order Pharmacy
50
- Generic Formulary $37 Copay Not Covered
50
- Brand Name Formulary $87 Copay Not Covered
- Non-Formulary $125 Copay Not Covered
- Supply Limit 90 Days N/A

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