Page 10 - Optima Tax EE Guide 01-19 AZ.pub

Medical Plan Highlights

United Healthcare
Plan Name HMO

Network Name Navigate Balanced HMO
Plan Differences
Employee Premiums $

Employee Cost Sharing Contribution, Copay

Network 
- Network Size 
- In-Network Benefits 
- Non-Network Benefits
Access to Providers Managed by Your PCP
Health Benefits
Lifetime Max Benefit Unlimited

Deductible (Cal Year)
- Individual $2,000
- Family $4,000
Out-of-Pocket Maximum
- Individual $6,000
- Family $12,000
Coinsurance (Plan Pays) 100%
Office Visit Copay
- Preventive Care No Charge
- PCP $35 Copay PCP Referred
$70 Copay Self-Referred
- Specialist $70 Copay
- Urgent Care $50 Copay
- Virtual Visits: Telehealth No Charge
- House Calls: Heal Not Covered

24/7 Nurseline No Charge
Hospitalization
- Inpatient Deductible, 20%

- Outpatient Surgery Deductible, 20%
Lab and X-Ray
- Diagnostic No Charge

- Complex $250 Copay, Deductible, 20%
Emergency Room Services Deductible, 20%
Chiropractic $70 Copay
Max 20 visits per Calendar Year
Acupuncture Not Covered

10 Employee Benefits