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 Facilities1 |
UHC Choice Network Hospitals1 |
Out-of-Network Doctors, Hospitals and Facilities6 |
|
| 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 Surgery1 |
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 |
|
| Colonoscopy3 |
$0 |
Not covered |
|
| Mammography4 |
$0 |
Not covered |
|
| Outpatient Diagnostic Lab & X-ray (Excluding MRI, CT, PET Scans)1 |
No additional charge if processed in doctor’s office; 10% after deductible if not in doctor’s office |
50% after deductible | |
| MRI, CT & PET Scans1 |
10% after deductible |
50% after deductible |
|
| Outpatient Therapy5 |
$30 per visit |
$50 per visit |
50% after deductible |
1 When 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 Choice 500 and Choice 1000 plans, while care at non-Preferred hospitals is only covered at 30% after the deductible. Talk to a Health Advocate at 1-877-MyTHRLink (1-877-698-4754) option 2, to verify whether a facility and/or doctor is covered under your plan and to learn how much your co-insurance would be.
2 Maximum includes deductible and copays for medical care. It does not include copays or coinsurance for prescriptions.
3 One well exam per year is 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.
4 One per year is covered. You pay the coinsurance for additional mammograms.
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.
6 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.
7 $1,000 penalty for failure to provide notification.