CHOICE PLUS PLAN 1500
Your Cost for Covered Medical Services
| Plan Features |
CHOICE PLUS PLAN 1500 |
||
|
UHC Choice Network Doctors, Preferred Hospitals and Free-standing Facilities8 |
UHC Choice Network Hospitals |
Out-of-Network Doctors, Hospitals and Facilities1 |
|
| Deductible |
$1,500 individual / |
$4,000 individual / |
$5,000 individual / |
| Medical and Rx Out-of-Pocket Maximum2 |
$6,850 individual / |
$18,000 individual / |
|
| Office Visits |
$30 copay for PCP; $50 copay for specialist |
50% after deductible |
|
| Maternity Office Visits |
$30 copay for initial office visit; |
50% after deductible |
|
| Inpatient Hospital Care |
10% after deductible |
50% after deductible with notification7 |
|
| Virtual Visits |
$0 |
||
| Emergency Room |
$100 copay, then 10% after deductible |
||
| Urgent Care Center |
$50 copay |
50% after deductible |
|
| Outpatient Surgery8 |
Office visit copay applies; |
50% after deductible |
50% after deductible with notification7 |
| Routine Physicals3 |
$0 |
Not covered |
|
| Well-Woman/Man Exams (Including Pap Test or PSA Test)3 |
$0 |
Not covered |
|
| Well-Child Care (Including Immunizations)3 |
$0 for first visit of the year, |
Not covered |
|
| Colonoscopy4 |
$0 |
Not covered |
|
| Mammography4 |
$0 |
Not covered |
|
| Outpatient Diagnostic Lab & X-ray (Excluding MRI, CT, PET Scans)6,8 |
No additional charge if processed in doctor’s office; 10% after deductible if not in doctor’s office |
50% after deductible | |
| MRI, CT & PET Scans6,8 |
10% after deductible |
50% after deductible |
|
| Outpatient Therapy5 |
$30 per visit |
$50 per visit |
50% after deductible |
1 Whenever you use an out-of-network provider, you pay for services when you receive them and file a claim for reimbursement of eligible expenses.
2 The annual out-of-pocket maximum includes the annual deductible, medical coinsurance, medical copays, prescription coinsurance and prescription copays. It does not include non-compliance penalties, your premiums, or expenses that are not covered by the plan.
3 Wellness exams are covered in full if the claims administrator determines the physical is for preventive care. Additional screenings or services will be considered diagnostic services and will be covered after you pay the applicable copay or deductible and coinsurance. At the time of your preventive care visit, if other services are performed that are not preventive services, as determined by the claims administrator, they will not be paid at 100% even if they are submitted as part of a claim for preventive care. Some items require you to pay the appropriate copay or coinsurance, including electrocardiograms (EKGs), focused office visits, thyroid scans, breast MRI, vitamin D assays, and transvaginal ultrasounds.
4 One per year is covered in full; additional screenings are covered, however you pay the coinsurance after your deductible.
5 Up to a combined total of 60 visits per year are covered for outpatient physical, occupational, and speech therapy. Pulmonary rehabilitation services are covered up to 20 visits. Up to 36 cardiac rehabilitation visits are covered. Up to a combined total of 20 visits per year are covered for Chiropractic, Acupuncture, and Spinal Manipulation.
6 Whenever you have an X-ray or lab service, you may incur two separate charges. One is for the service itself, and the other is for the radiologist or pathologist who interprets the results. The radiologist or pathologist must be in-network for charges to be covered under Texas Health Aetna Select 1000, UHC Choice 500 and UHC Choice 1000.
7 $1,000 penalty for failure to obtain prior authorization.
8When your doctor requests tests or services such as lab work, X-rays, MRIs, CT scans, physical therapy or rehabilitation at a free-standing facility that isn’t affiliated with a hospital, you should check the coinsurance level of that facility on your plan. Services performed at Preferred Hospitals or at a free-standing facility unaffiliated with a hospital are covered at 90% after deductible by the Texas Health Aetna Select Plan 1000 and the UHC Choice 500 and Choice 1000 plans, while care at non-Preferred hospitals is only covered at 30% after the deductible. Check with your plan administrator to verify whether a facility and/or doctor is covered under your plan and to learn how much your coinsurance would be.