Medical Benefits

Your employer offers medical insurance that covers expenses such as visits to the doctor’s office, emergency care, and prescription drugs. Keep in mind that your out-of-pocket costs will be lower if you receive care from an in-network doctor and facility. To find a doctor in the Network please visit www.uhc.com/find-a-doctor.

	In-Network	Non-Network
Coinsurance	20%	N/A
Deductible (Individual/Family)	$1,500 / $3,000	N/A
Out-of-Pocket Max (Individual/Family)	$3,250 / $6,500	N/A

Physician Visits	In-Network	Non-Network
Primary Care	Age 0-18 $0 Copay Age 19+ $30 Copay	N/A
Routine Preventive	$0 Copay	N/A
Specialist	$60 Copay	N/A
Telehealth/Virtual Visits	Telehealth: Applicable OV Copay >br>Virtual: $0 Copay (DNP)	N/A
Vision	$30 Copay; once every 24 months	N/A

Hospital Services	In-Network	Non-Network
Inpatient Hospitalization	Deductible + 20%	N/A
Physician Services	Deductible + 20%	N/A
Outpatient Surgery	Deductible + 20%	N/A
Outpatient Diagnostics	Lab Testing: DN-Deductible+20% Other-Deductible+30% X-Ray: Deductible + 20% Major (MRI, CAT, etc.): DN-Deductible +20% Other: Deductible + 30%	N/A
Urgent Care Visit	$50 Copay	N/A
Emergency Room Visit	Deductible + 20%	Deductible + 20%

Prescriptions	In-Network	Non-Network
Retail Prescriptions
Level 1/2/3	$10 / $35 / $70 Copay	N/A
Mail Order Prescriptions
Level 1/2/3	$25 / $87.50 / $175 Copay	N/A

	Bi-Weekly Employee Contribution	Monthly Employee Contribution	Monthly Employer Contribution
Employee	$84.98	$184.13	$925.00
Employee + Spouse	$648.08	$1,404.17	$925.00
Employee + Child(ren)	$494.51	$1,071.44	$925.00
Employee + Family	$1,108.80	$2,402.39	$925.00

Downloads

Summary of Benefits

UHC Digital Engagement Flyer

UHC Simple Ways to Save

UHC Welcome- with Rx

	In-Network	Non-Network
Member Coinsurance	20%	50%
Deductible (Individual/Family)	$5,000/$10,000	$10,000 / $20,000
Out-of-Pocket Max (Individual/Family)	$7,150 / $14,300	$20,000 / $40,000

Physician Visits	In-Network	Non-Network
Primary Care	Age 0-18 $0 Copay Age 19+ $15 Copay	Deductible + 50%
Routine Preventive	$0 Copay	Deductible + 50%
Specialist	$50 DSN / $100 SPC	Deductible + 50%
Telehealth/Virtual Visits	Telehealth: Applicable OV Copay Virtual: $0 Copay (DNP)	Deductible + 50%
Vision	$15 Copay; once every 24 months	Deductible + 50%

Hospital Services	In-Network	Non-Network
Inpatient Hospitalization	Deductible + 20%	Deductible + 50%
Physician Services	Deductible + 20%	Deductible + 50%
Outpatient Surgery	Surgery: Deductible + 20% Scope: $500 Copay	Deductible + 50%
Outpatient Diagnostics	Lab Testing: DN-Deductible+20% Other-Deductible+30% X-Ray: Deductible + 20% Major (MRI, CAT, etc.): DN-Deductible +20% Other: Deductible + 30%	Deductible + 50%
Urgent Care Visit	$25 Copay	Deductible + 50%
Emergency Room Visit	Deductible + 20%	Deductible + 20%

Prescriptions	In-Network	Non-Network
Retail Prescriptions
Level 1/2/3	$10 / $35 / $70 Copay	Retail Copay + 50%
Mail Order Prescriptions
Level 1/2/3	$25 / $87.50 / $175 Copay	N/A

	Bi-Weekly Employee Contribution	Monthly Employee Contribution	Monthly Employer Contribution
Employee Only	$76.98	$166.79	$925.00
Employee + Spouse	$631.27	$1,367.75	$925.00
Employee + Child(ren)	$480.11	$1,040.23	$925.00
Employee + Family	$1,084.79	$2,350.37	$925.00

Downloads

Summary of Benefits

UHC Digital Engagement Flyer

UHC Simple Ways to Save

UHC Welcome- with Rx

	In-Network	Non-Network
Member Coinsurance	20%	50%
Deductible (Individual/Family)	$2,000 / $4,000	$5,000 / $10,000
Out-of-Pocket Max (Individual/Family)	$6,000 / $12,000	$10,000 / $20,000

Physician Visits	In-Network	Non-Network
Primary Care	Age 0-18 $0 Copay Age 19+ $30 Copay	Deductible + 50%
Routine Preventive	$0 Copay	Deductible + 50%
Specialist	$30 DSN / $60 SPC	Deductible + 50%
Telehealth/Virtual Visits	Telehealth: Applicable OV Copay Virtual: $0 Copay (DNP)	Deductible + 50%
Vision	$30 Copay; ; once every 24 months	Deductible + 50%

Hospital Services	In-Network	Non-Network
Inpatient Hospitalization	Copay + 20%	Deductible + 50%
Physician Services	Copay + 20%	Deductible + 50%
Outpatient Surgery	Surgery: Deductible + 20% Scope: $500 Copay	Deductible + 50%
Outpatient Diagnostics	Lab Testing: DN-$0 Copay Other-Copay+10% X-Ray: $0 Copay Major (MRI, CAT, etc.): DN-Copay + 20% Other: Copay + 30%	Deductible + 50%
Urgent Care Visit	$50 Copay	Deductible + 50%
Emergency Room Visit	$250 Copay + 20%	$250 Copay + 20%

Prescriptions	In-Network	Non-Network
Retail Prescriptions
Level 1/2/3/4	$10 / $35 / $70 Copay	Retail Copay + 50%
Mail Order Prescriptions
Level 1/2/3/4	$25 / $87.50 / $175 Copay	N/A

	Bi-Weekly Employee Contribution	Monthly Employee Contribution	Monthly Employer Contribution
Employee Only	$186.43	$403.93	$925.00
Employee + Spouse	$861.11	$1,865.74	$925.00
Employee + Child(ren)	$677.11	$1,467.08	$925.00
Employee + Family	$1,413.13	$3,061.79	$925.00