Medical Benefits Summary

                                                     Provided by United Health Care

 
PLAN:
NETWORK:
BENEFITS:


OFFICE VISITS


Primary Care
 

Physician Services in
Office Setting



Specialist



 



Referrals Required
Urgent Care Centers


Emergency Room



Diagnostic Clinical Lab:
Quest or LabCorp
Advanced Imaging
( MRI / CT /  PET)


In-Patient



Out-Patient / Ambulatory
Surgery Center
PREVENTATIVE

Well Child
Adult Wellness
Preventive Clinical Lab:
Quest or LabCorp
  
CORE PLAN BLQZ /NHDX BUY UP Plan AQOI / 570
NHP - Direct Access Choice - National Network
IN NETWORK IN NETWORK


Premium Care:
$25 Copay


$25 Copay

Non-Premium Care
$75 Copay



Additional Fees
May Apply



Additional Fees
May Apply
Premium Care:
$50 Copay
$50 Copay
Non-Premium Care:
50% Coinsurance after Ded



No - MUST SELECT PCP No
$50 Copay


$75  Copay
$350 Copay then 50% Coinsurance after Ded


$250  Copay
50% Coinsurance after Ded Covered at 100%
$250 Copay then 50% Coinsurance after Ded


20% Coinsurance
after Ded
$500 Copay then 50% Coinsurance after Ded


20% Coinsurance
after Ded
$350 Copay then 50% Coinsurance after Ded 20% Coinsurance
after Ded


Covered at 100%

Covered at 100%
Covered at 100%

Covered at 100%

Covered at 100%

Covered at 100%






Prescription Drug Plan NHDX

Prescription Drug Plan 570

 


Tier 1 


Tier 2 
Tier 3 
Tier 4
 
Tier 1 

Tier 2 

Tier 3 

Tier 4
 
Pharmacy: Retail 30 day
$15.00

$10.00
$45.00 $35.00
$85.00 $70.00
$200.00 Not Applicable
Pharmacy: Mail Order 90 Days

$37.50

$25.00
$112.50

$87.50
$212.50

$175.00
$500.00 Not Applicable 




CALENDAR YEAR DEDUCTIBLE
 

Individual


Family


 Member Cost Share 


$3,000 Per Person


$2,500 Per Person
$6,000 Family Maximum $5,000 Family Maximum


 50%20% 

CALENDAR YEAR OUT-OF-POCKET MAXIMUM (OOP)
 
Individual
Family
$7,350 Per Person $6,250 Per Person
$14,700 Family Maximum $12,500 Family Maximum
 ALL OUT OF NETWORK BENEFITS ARE SUBJECT TO OUT OF NETWORK DEDUCTIBLE AND COINSURANCE

*
This site provides a brief summary of your plans; it is not a contract. Please see insurance contracts (available from Human Resources) for complete details and limitations.