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UHC Options HSA Plan
Medical plan options provided through UnitedHealthcare.
Plan Details
Network
UnitedHealthcare
Plan Type
HDHP + HSA
HSA Eligible
Yes
FSA Eligible
Yes
Premium Contributions
| Coverage Tier | Per-Paycheck Contribution |
|---|---|
| Employee Only | $0.00 |
| Employee + Spouse | $186.56 |
| Employee + Child(ren) | $139.76 |
| Employee + Family | $266.51 |
Employee Only
- Per-Paycheck Contribution
- $0.00
Employee + Spouse
- Per-Paycheck Contribution
- $186.56
Employee + Child(ren)
- Per-Paycheck Contribution
- $139.76
Employee + Family
- Per-Paycheck Contribution
- $266.51
Covered Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Deductible (Individual/Family) | $3,400 / $6,800 | $6,000 / $12,000 |
| Out-of-Pocket Max (Individual/Family) | $5,000 / $10,000 | $10,000 / $20,000 |
| Office Visits (physician/specialist) | 10%* | 30%* |
| Routine Preventive Care | No charge | 30%* |
| Diagnostics (lab/X-ray) | 10%* | 30%* |
| Complex Imaging | 10%* | 30%* |
| Chiropractic | 10%* | Not covered |
| Ambulance | 10%* | 10%* |
| Emergency Room | 10%* | 10%* |
| Urgent Care Facility | 10%* | 30%* |
| Inpatient Hospital Stay | 10%* | 30%* |
| Outpatient Surgery | 10%* | 30%* |
Deductible (Individual/Family)
- In-Network
- $3,400 / $6,800
- Out-of-Network
- $6,000 / $12,000
Out-of-Pocket Max (Individual/Family)
- In-Network
- $5,000 / $10,000
- Out-of-Network
- $10,000 / $20,000
Office Visits (physician/specialist)
- In-Network
- 10%*
- Out-of-Network
- 30%*
Routine Preventive Care
- In-Network
- No charge
- Out-of-Network
- 30%*
Diagnostics (lab/X-ray)
- In-Network
- 10%*
- Out-of-Network
- 30%*
Complex Imaging
- In-Network
- 10%*
- Out-of-Network
- 30%*
Chiropractic
- In-Network
- 10%*
- Out-of-Network
- Not covered
Ambulance
- In-Network
- 10%*
- Out-of-Network
- 10%*
Emergency Room
- In-Network
- 10%*
- Out-of-Network
- 10%*
Urgent Care Facility
- In-Network
- 10%*
- Out-of-Network
- 30%*
Inpatient Hospital Stay
- In-Network
- 10%*
- Out-of-Network
- 30%*
Outpatient Surgery
- In-Network
- 10%*
- Out-of-Network
- 30%*
- If you use an out-of-network provider, you will be responsible for any charges above the maximum allowed amount.
- The deductible is embedded. This means that once a family member meets their individual deductible, the plan will begin to pay coinsurance for that family member.
- The out-of-pocket maximum is embedded. This means that, once an individual family member meets their out-of-pocket maximum, that individual’s expenses are covered at 100%.
Pharmacy Benefits
| Tier | In-Network | Out-of-Network |
|---|---|---|
| Retail (30-day supply) – Tier 1 | $10* | $10* |
| Retail (30-day supply) – Tier 2 | $30* | $30* |
| Retail (30-day supply) – Tier 3 | $50* | $50* |
| Retail (30-day supply) – Specialty | Copay based on tier level* | Copay based on tier level* |
| Mail Order (90-day supply) – Tier 1 | $20* | Not covered |
| Mail Order (90-day supply) – Tier 2 | $60* | Not covered |
| Mail Order (90-day supply) – Tier 3 | $100* | Not covered |
Retail (30-day supply) – Tier 1
- In-Network
- $10*
- Out-of-Network
- $10*
Retail (30-day supply) – Tier 2
- In-Network
- $30*
- Out-of-Network
- $30*
Retail (30-day supply) – Tier 3
- In-Network
- $50*
- Out-of-Network
- $50*
Retail (30-day supply) – Specialty
- In-Network
- Copay based on tier level*
- Out-of-Network
- Copay based on tier level*
Mail Order (90-day supply) – Tier 1
- In-Network
- $20*
- Out-of-Network
- Not covered
Mail Order (90-day supply) – Tier 2
- In-Network
- $60*
- Out-of-Network
- Not covered
Mail Order (90-day supply) – Tier 3
- In-Network
- $100*
- Out-of-Network
- Not covered
- *Benefits with an asterisk ( * ) require that the deductible be met before the Plan begins to pay.
Plan Notes
- You pay the full cost of non-preventive health care services and prescription drugs until you meet the annual deductible. The deductible is waived for in-network routine preventive care services and medications on the preventive drug list.
- The HDHP includes copays for prescription drugs only. You must meet the annual deductible before prescription copays apply.
- Once you meet the annual deductible, you pay a percentage of your health care expenses (coinsurance), and the plan pays the rest.
- Once your deductible and coinsurance add up to the out-of-pocket maximum, this plan pays the full cost of all qualified health care services for the rest of the year.