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Domestic Health and Prescription Plan and
Rates
Plan
Basics:
An
eligible employee has the option to choose between one of the 3 plan
options. There is an “Executive
Summary” which follows for each plan, and additionally, there is a full
benefit summary available by clicking the link following each Executive
Summary. A link to the
Prescription Summary may be found at the bottom of health plan outlines.
If you would like to see the latest list of doctors in
the United Healthcare Network, here is the website:
www.myuhc.com.
Here are some comments which may help you decide on the
best option to suit your needs:
Plan V5A is an HMO plan
with a local network. Care must
be provided by a network member in order to qualify for benefits.
Also important to note is
that this plan is a Health Savings Account (HSA) option,
This means that there is a large deductible which must be satisfied prior to being eligible
for most benefits.
For more information about an HSA type of plan,
click here. This is
the lowest premium plan.
Plan Y3F is a PPO plan
that uses the United Healthcare national network. With a PPO, you
may qualify for benefits whether or not your physician is a member of the
United Healthcare network.
Benefits are better when care and
treatment is received from a network provider.
This plan does have a deductible
which must be satisfied for items which may be more involved than a
basic office visit.
This plan also features discounts
for utilizing cost efficient providers.
Plan V3M is also a PPO
plan that uses the United Healthcare national network. With this PPO,
you also may receive benefits whether or not your
service provider is a
member of the United Healthcare network.
This plan is the most flexible of all the plans offered, and is also
the most expensive in terms of monthly
premiums.
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United Health Care
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Definity HSA Plan V5A-H9
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Medical Benefits
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In-Network
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Primary Care Physician Office Visit
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$30 Co-pay after Deductible
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Specialist Office Visit
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$60 Co-pay After Deductible
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Annual Deductible (ind./fam.)
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$1250/$2500
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Out of Pocket Max (ind./fam.)
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$2500/$5000
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Prescription Coverage:
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$10/$30/$50 after deductible
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(Generic/Formulary/Non-Formulary)
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Diagnostic Services
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No Charge after deductible
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Xray & Lab tests
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No Charge after deductible
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Routine Mammograms
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No Charge
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CAT, PET, MRI,MRA/MRS
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No Charge after deductible
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Outpatient Surgery
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$250 Co-pay after deductible
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Emergency Room (Waived if Admitted)
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$200 Co-pay after deductible
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Urgent Care Center
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$100 Co-pay after deductible
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Inpatient Hospitalization
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$500 Co-pay after deductible
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Phys. Therapy, Speech, Occ. Therapy
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$30 Co-pay after deductible
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Vision Coverage (Routine Eye Exam)
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$30 Co-pay after deductible
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Network Web Address
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www.myuhc.com
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Out-of-Network
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Primary Care Physician Office Visit
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No Coverage
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Specialist Office Visit
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No Coverage
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Annual Deductible (ind./fam.)
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N/A
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Out of Pocket Max (ind./fam.)
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N/A
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Diagnostic Laboratory
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No Coverage
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Diagnostic XRay
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No Coverage
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Routine Mammograms
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No Coverage
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CAT, PET, MRI,MRA/MRS
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No Coverage
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Outpatient Surgery
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No Coverage
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Emergency Room (Waived if Admitted)
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$200 Co-pay after deductible
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Urgent Care Center
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No Coverage
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Inpatient Hospitalization
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No Coverage
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Phys. Therapy, Speech, Occ. Therapy
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No Coverage
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Vision Coverage (Routine Eye Exam)
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No Coverage
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Lifetime Maximum (In/Out of Network)
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No Limit/$0
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Click
here to see Full Benefit Summary for
United V5A-H9
Plan Y3F
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United Health Care
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Choice Plus EDGE Y3F-H9
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Medical Benefits
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In-Network
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Primary Care Physician Office Visit
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$30 Co-pay
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Specialist Office Visit
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$60 Co-pay
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Annual Deductible (ind./fam.)
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$1000/$3000
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Out of Pocket Max (ind./ind. + 1/fam.)
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$3000/$6000
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Prescription Coverage:
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$10/$30/$50
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(Generic/Formulary/Non-Formulary)
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Diagnostic Services
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No Charge after deductible
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Xray & Lab tests
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No Charge after deductible
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Routine Mammograms
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No Charge
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CAT, PET, MRI,MRA/MRS
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No Charge after deductible
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Outpatient Surgery
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$250 Co-pay after deductible
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Emergency Room (Waived if Admitted)
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$250 Co-pay
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Urgent Care Center
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$100 Co-pay
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Inpatient Hospitalization
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$500 Co-pay after deductible
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Phys. Therapy, Speech, Occ. Therapy
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$30 Co-pay
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Vision Coverage (Routine Eye Exam)
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$30 Co-pay
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Network Web Address
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www.myuhc.com
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Out-of-Network
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Primary Care Physician Office Visit
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30% after deductible
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Specialist Office Visit
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30% after deductible
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Annual Deductible (ind./fam.)
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$2000/$6000
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Out of Pocket Max (ind./fam.)
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$6000/$12000
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Diagnostic Laboratory
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30% after deductible
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Diagnostic XRay
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30% after deductible
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Routine Mammograms
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No Coverage
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CAT, PET, MRI,MRA/MRS
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30% after deductible
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Outpatient Surgery
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30% after deductible and $250 Co-pay
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Emergency Room (Waived if Admitted)
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$250 Co-pay
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Urgent Care Center
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30% after deductible
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Inpatient Hospitalization
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30% after deductible and $500 Co-pay
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Phys. Therapy, Speech, Occ. Therapy
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30% after deductible
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Vision Coverage (Routine Eye Exam)
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No Coverage
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Lifetime Maximum (In/Out of Network)
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$5 million combined
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Click to
see full benefit summary for United Y3F benefit summary
Plan United V3-M (see
PDF)
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United
Healthcare |
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Medical Benefits |
Choice Plus V3-M Plan |
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In-Network |
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Primary Care Physician Office Visit |
$20 Copay |
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Specialist Office Visit |
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$40 Copay |
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Annual Deductible (ind./fam.) |
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$500/$1500 |
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Out of Pocket Max (ind./fam.) |
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$2500/$7500 |
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Prescription Coverage: |
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$10/$30/$50 |
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(Generic/Formulary/Non-Formulary) |
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Diagnostic Services |
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No Charge |
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Xray & Lab tests |
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No Charge |
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Routine Mammograms |
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No Charge |
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CAT, PET, MRI,MRA/MRS |
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10% after deductible |
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Outpatient Surgery |
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10% after deductible |
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Emergency Room (Waived if Admitted) |
$150 Copay |
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Urgent Care Center |
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$75 Copay |
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Inpatient Hospitalization |
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10% after deductible |
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Phys. Therapy, Speech, Occ. Therapy |
$20 Copay |
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Vision Coverage (Routine Eye Exam) |
$20 Copay |
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Network Web Address |
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www.myuhc.com |
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Out-of-Network |
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Primary Care Physician Office Visit |
30% after deductible |
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Specialist Office Visit |
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30% after deductible |
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Annual Deductible (ind./fam.) |
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$1000/$3000 |
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Out of Pocket Max (ind./fam.) |
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$6000/$12000 |
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Diagnostic Services |
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30% after deductible |
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Xray & Lab tests |
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30% after deductible |
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Routine Mammograms |
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30% after deductible |
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CAT, PET, MRI,MRA/MRS |
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30% after deductible |
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Outpatient Surgery |
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30% after deductible |
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Emergency Room (Waived if Admitted) |
$150 Copay |
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Urgent Care Center |
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30% after deductible |
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Inpatient Hospitalization |
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30% after deductible |
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Phys. Therapy, Speech, Occ. Therapy |
30% after deductible |
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Vision Coverage (Routine Eye Exam) |
None |
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Lifetime Maximum (In/Out of Network) |
unlimited |
Click
to full benefit summary for
United V3M
benefit summary
Click here to see
United Rx
Plan H9 (HSA plan V5A uses the same H9 Rx plan, but the Rx is still
subject to the deductible):
Monthly
Premiums:
2011- 2012 United HealthCare Plan
OBO/USAID/INL
Domestic Plan Rate Chart |
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United HealthCare Definity HSA Plan V5A w/ H9 RX |
United HealthCare Choice Plus Edge Plan Y3F w/ H9 RX |
United HealthCare Choice Plus V3-M Plan w/ H9 RX |
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Employee/Single |
$597.85 |
$658.20 |
$735.53 |
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Per Pay Period |
$298.93 |
$329.10 |
$367.77 |
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COBRA |
$609.81 |
$671.36 |
$750.24 |
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Employee & Spouse |
$1,255.50 |
$1,382.21 |
$1,544.60 |
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Per Pay Period |
$627.75 |
$691.11 |
$772.30 |
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COBRA |
$1,280.61 |
$1,409.85 |
$1,575.49 |
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Employee & Child |
$1,028.31 |
$1,132.10 |
$1,265.10 |
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Per Pay Period |
$514.16 |
$566.05 |
$632.55 |
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COBRA |
$1,048.88 |
$1,154.74 |
$1,290.40 |
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Family |
$1,805.53 |
$1,987.75 |
$2,221.29 |
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Per Pay Period |
$902.77 |
$993.88 |
$1,110.65 |
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COBRA |
$1,841.64 |
$2,027.51 |
$2,265.72 |
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