UHC Options PPO 750 Plan

Medical plan options provided through UnitedHealthcare.

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Plan Details

Network

UnitedHealthcare

Plan Type

PPO

HSA Eligible

FSA Eligible

Yes

Premium Contributions

Coverage Tier	Per-Paycheck Contribution
Employee Only	$39.09
Employee + Spouse	$273.44
Employee + Child(ren)	$200.50
Employee + Family	$431.85

Employee Only

Per-Paycheck Contribution: $39.09

Employee + Spouse

Per-Paycheck Contribution: $273.44

Employee + Child(ren)

Per-Paycheck Contribution: $200.50

Employee + Family

Per-Paycheck Contribution: $431.85

Covered Services

Service	In-Network	Out-of-Network
Deductible (Individual/Family)	$750 / $1,500	$1,500 / $3,000
Out-of-Pocket Max (Individual/Family)	$3,000 / $6,000	$6,000 / $12,000
Office Visits (physician/specialist)	$25 / $50 copay	40%*
Routine Preventive Care	No charge	Not covered
Diagnostics (lab/X-ray)	10%	40%*
Complex Imaging	10%*	40%*
Chiropractic	$25 copay	Not covered
Ambulance	10%	10%*
Emergency Room	$250 copay	$250 copay
Urgent Care Facility	$75 copay	40%*
Inpatient Hospital Stay	10%*	40%*
Outpatient Surgery	10%*	40%*

Deductible (Individual/Family)

In-Network: $750 / $1,500
Out-of-Network: $1,500 / $3,000

Out-of-Pocket Max (Individual/Family)

In-Network: $3,000 / $6,000
Out-of-Network: $6,000 / $12,000

Office Visits (physician/specialist)

In-Network: $25 / $50 copay
Out-of-Network: 40%*

Routine Preventive Care

In-Network: No charge
Out-of-Network: Not covered

Diagnostics (lab/X-ray)

In-Network: 10%
Out-of-Network: 40%*

Complex Imaging

In-Network: 10%*
Out-of-Network: 40%*

Chiropractic

In-Network: $25 copay
Out-of-Network: Not covered

Ambulance

In-Network: 10%
Out-of-Network: 10%*

Emergency Room

In-Network: $250 copay
Out-of-Network: $250 copay

Urgent Care Facility

In-Network: $75 copay
Out-of-Network: 40%*

Inpatient Hospital Stay

In-Network: 10%*
Out-of-Network: 40%*

Outpatient Surgery

In-Network: 10%*
Out-of-Network: 40%*

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

Plan Notes

You pay a flat dollar amount—or copay—for covered health care treatments and services, such as doctor’s office visits and prescription drugs.
Once you satisfy your annual deductible, you will pay a percentage—or coinsurance—of the cost of the visit, and the plan will cover the rest.
Once you hit your annual out-of-pocket maximum, the plan will cover 100% of the cost of covered services for the rest of the year.