Choice Plan 1500

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 /
$4,500 family

$4,000 individual /
$12,000 family

$5,000 individual /
$15,000 family

Medical and Rx Out-of-Pocket Maximum2

$6,850 individual /
$13,700 family

$18,000 individual /
$36,000 family

Office Visits

$30 copay for PCP; $50 copay for specialist

50% after deductible

Maternity Office Visits

$30 copay for initial office visit;
no cost for additional visits

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;
10% after deductible if not in doctor’s office

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,
$30 copay for additional visits during 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.