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Medical Insurance

UnitedHealthcare UnitedHealthcare
Plan Name Silver Select Plus PPO (BR-J7) Gold Select Plus (BR-J6)

Network Name In-Network Non-Network In-Network Non-Network
Health Benefits
Lifetime Maximum Unlimited Unlimited

Deductible (Annual)
- Individual $1,500 $3,000 $1,500 $3,000
- Family $3,000 $6,000 $3,000 $6,000

Co-Insurance (Plan Pays) 60% 50% 70% 50%
Office Visit Copay
- Primary Care Physician $50 Copay Deductible, 50% $0 Copay Deductible, 50%
- Specialist Office Visit $80 Copay Deductible, 50% $75 Copay Deductible, 50%

Out-of-Pocket Maximum
- Individual $8,150 $16,300 $6,500 $13,000
- Family $16,300 $32,600 $13,000 $26,000
Hospitalization
- Inpatient $250, Ded., 40% $250, Ded., 50% $250, Ded., 30% $250, Ded., 50%
- Outpatient $250, Ded., 40% $250, Ded., 50% $250, Ded., 30% $250 Ded., 50%

Lab and X-Ray
- Free Standing Deductible, 40% Deductible, 50% Deductible, 30% Deductible, 50%
- Hospital Deductible, 50% Deductible, 50% Deductible, 30%/50% Deductible, 50%
Emergency Services Deductible, $300 Copay, 40% Deductible, $250 Copay, 30%
Urgent Care $80 Copay Deductible, 50% $50 Copay Deductible, 50%

Preventive Care No Charge Not Covered No Charge Not Covered
Chiropractic $45 Copay Deductible, 50% $25 Copay Deductible, 50%
24 Visits/Year 24 Visits/Year

Pharmacy Benefits
Pharmacy Deductible
- Individual $300 $250
- Family $600 $500

Retail Pharmacy
- Generic Formulary $20 Copay $20 Copay $5 Copay $5 Copay
- Brand Name Formulary $50 Copay $50 Copay $50 Copay $50 Copay
- Non-Formulary $100 Copay $100 Copay $100 Copay $100 Copay
- Supply Limit 30 Days 30 Days 30 Days 30 Days

Mail Order Pharmacy
- Generic Formulary $50 Copay Not Covered $12.50 Copay Not Covered
- Brand Name Formulary $125 Copay Not Covered $125 Copay Not Covered
- Non-Formulary $250 Copay Not Covered $250 Copay Not Covered
- Supply Limit 90 Days N/A 90 Days N/A

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