Deductible

The amount of covered expenses that the insured must pay before a plan or insurance contract starts to pay.

$0.0

Coinsurance

Most policies require the insured to pay some portion of the health care bills. A typical arrangement is that the insurer pays 80 percent and the insured 20 percent, up to $3,000 of covered expenses after the insured has paid the deductible. After the insured hits the maximum out-of-pocket limit, the insurance company pays 100 percent of covered expenses during the remainder of the calendar year, up to any applicable annual benefit or lifetime maximum of the policy.

None

Coinsurance Out-of-Pocket Maximum

The limit on the amount an individual is required to pay for health care services covered by his or her benefits plan after the deductibles and any copays are paid. Refers to care received from the network of participating physicians, hospitals, and health care professionals. Coinsurance Out-of-Pocket amounts are in addition to any Deductible amounts.

0.0

Network

A group of doctors, hospitals and other health care providers and facilities that have, either, (i) contracted with a health insurer or health plan to provide medical services at negotiated or discounted rates, or (ii) for limited benefits supplemental coverage, contracted directly or indirectly with an underwriter to agree to reduced fees for medical services.

UnitedHealthcare Choice Plus

Surgical Procedure (inpatient or outpatient) Procedures are based on Tiers 1-7

Benefits range from $500 (Tier 7) - $50,000 (Tier 1). Unlimited days; multiple surgeries in a day will only pay the highest tier. For Surgery Tier benefit details, see product brochure

Anesthesiologist

30% of surgical benefits payable per day

Assistant Surgeon

20% of surgical benefits payable per day

Outpatient Facility

$2,500 per day (3 days)

Rx Brand/Generic

$60/$10 per fill

Maximum Rx fill, per calendar year (combined Brand Name and Generic)

15 fills

HealthiestYou by Teladoc Health (Telemedicine)

Included with plan; access to 24/7 virtual doctor visits for common medical issues via HealthiestYou app; see product brochure for more detail

Rx Discount Card - Optum Perks

Included with plan; access to discounts on prescription drugs of 30%-80%. Present card to pharmacy for discounts; see product brochure for more details.

Lab

$75 per test

X-ray and other diagnostic testing (see brochure for list)

$100 per test

Diagnostic and Imaging Tier 2 (MRI/PET/CAT)

$500 per test

Total Outpatient Tests, per calendar year (any of the above listed type)

5 tests

Oral Chemotherapy

$1,000 per month (3 months)

Chemotherapy (non oral), Radiation, and Immunotherapy

$2,000 per day (40 days)

Emergency Room

$1,000 per day (1 day)

Hospital Stay

$5,000 per day, Unlimited days

Intensive Care Unit (ICU)

$5,000 per day (31 days) Benefit amount in addition to Hospital Stay

Ground or Water Ambulance

$1,000 per trip

Air Ambulance

$5,000 per trip

Maximum Ambulance trips, per calendar year (any type)

2 trips

WORx Level

Level 2

Hospital Benefit Level

Premier

Calendar Year Benefit Maximum

$2 Million

Lifetime Benefit Maximum

$5 Million

Rate Guarantee

12-Month

Wellness Exam

$100 per exam (1 exam)

Health Screening Diagnostic Labs

$50 per test (2 tests)

Health Screening X-ray

$50 per test (1 test)

Child Immunizations & Flu Shot

$25 per immunization (4 immunizations)

Pap Smear/PSA Test

$100 per exam (1 exam)

Adult Annual Flu Shot

$25 per treatment (1 treatment)

Child Allergy (under age 18)

$10 per treatment (10 treatments)

Mammogram

$150 per exam (1 exam)

Colonoscopy

$300 per exam (1 exam)

Bone Density

Not covered

EKG

Not covered

Stress EKG

Not covered

Office Visit

$100 per visit for illness or injury

Specialist Visits (no referral required)

$125 per visit

Urgent Care Visits

$125 per visit

Office Visit with In-Office Surgery (in place of the office visits listed above)

$225 per visit

Total Office Visits, per calendar year (any of above listed type)

5 visits

Chiropractic Therapy

$35 per visit

Physical Therapy

$35 per visit

Occupational Therapy

$35 per visit

Speech Therapy

$35 per visit

Total Therapy Visits, per calendar year (any of the above listed type)

10 visits