Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums– the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
UHC Choice Plus Base PPO
Plan Information
Plan Name: UHC Choice Plus Base PPO
Policy Number: CZTU/G85S
Effective Date: 11/01/2024
Provider Network: UnitedHealthcare
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$2,000/$4,000
Out-of-Pocket Max (Individual/Family)
$6,250/$12,500
Preventive Care
$0
Primary Care Visit
$30 copay
Specialist Visit
$60 copay
Urgent Care
$50 copay
Emergency Room
$350 copay
Retail Rx (Up to 31-Day Supply)
Tier 1
$10 copay
Tier 2
$45 copay
Tier 3
$80 copay
Specialty
$250 copay
Mail Order Rx (Up to 90-Day Supply)
Tier 1
$25 copay
Tier 2
$112.50
Tier 3
$200 copay
Specialty
$625 copay
Out-of-Network
Deductible (Individual/Family)
$4,000/$8,000
Out-of-Pocket Max (Individual/Family)
$12,000/$24,000
Preventive Care
50% coinsurance
Primary Care Visit
50% coinsurance
Specialist Visit
50% coinsurance
Urgent Care
50% coinsurance
Emergency Room
$350 copay
Retail Rx (Up to 31-Day Supply)
Tier 1
$10 copay
Tier 2
$45 copay
Tier 3
$80 copay
Specialty
$250 copay
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
Not covered
Tier 2
Not covered
Tier 3
Not covered
Specialty
Not covered
Plan Documents
Contact Information
UHC Choice Plus Buy-Up PPO
Plan Information
Plan Name: UHC Choice Plus Buy-Up PPO
Policy Number: CZTG /G85
Effective Date: 11/01/2024
Provider Network: UnitedHealthcare
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$5,500/$11,000
Preventive Care
$0
Primary Care Visit
$30 copay
Specialist Visit
$60 copay
Urgent Care
$75 copay
Emergency Room
$300 copay
Retail Rx (Up to 31-Day Supply)
Generic
$10 copay
Preferred Brand
$45 copay
Non-Preferred Brand
$80 copay
Specialty
$250 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$25 copay
Preferred Brand
$112.50 copay
Non-Preferred Brand
$200 copay
Specialty
$625 copay
Out-of-Network
Deductible (Individual/Family)
$5,000/$10,000
Out-of-Pocket Max (Individual/Family)
$10,000/$20,000
Preventive Care
50% coinsurance
Primary Care Visit
50% coinsurance
Specialist Visit
50% coinsurance
Urgent Care
50% coinsurance
Emergency Room
$300 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$45 copay
Non-Preferred Brand
$80 copay
Specialty
$250 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Contact Information
UHC Options PPO HSA
Plan Information
Plan Name: UHC Options PPO HSA
Policy Number: DJS8 /01
Effective Date: 11/01/2024
Provider Network: UnitedHealthcare
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$3,200/$6,400
Out-of-Pocket Max (Individual/Family)
$5,500/$11,000
Preventive Care
$0
Primary Care Visit
20% coinsurance
Specialist Visit
20% coinsurance
Urgent Care
20% coinsurance
Emergency Room
20% coinsurance
Retail Rx (Up to 31-Day Supply)
Generic
$10 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$70 copay
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
$25 copay
Preferred Brand
$87.50 copay
Non-Preferred Brand
$175 copay
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$6,000/$12,000
Out-of-Pocket Max (Individual/Family)
$12,000/$24,000
Preventive Care
50% coinsurance
Primary Care Visit
50% coinsurance
Specialist Visit
50% coinsurance
Urgent Care
50% coinsurance
Emergency Room
20% coinsurance
Retail Rx (Up to 31-Day Supply)
Generic
$10 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$70 copay
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered