Choice Plan 500 and Choice Plan 1000

CHOICE PLAN 500 AND CHOICE PLAN 1000

Your Cost for Covered Medical Services

Deductible and Out-of-Pocket Maximum

UHC Choice Network Doctors, Preferred Hospitals and Free-standing Facilities1

UHC Choice
Network Hospitals1

Choice Plan 500 Deductible

$500 individual /
$1,500 family

$3,000 individual /
$9,000 family

Medical and Rx Out-of-Pocket Maximum2

$6,850 individual / $13,700 family

Choice Plan 1000 Deductible

$1,000 individual /
$3,000 family

$4,000 individual /
$12,000 family

Medical and Rx Out-of-Pocket Maximum2

$6,850 individual / $13,700 family

Plan Features

CHOICE PLANS 500 AND 1000

UHC Choice Network
Doctors, Preferred Hospitals and
Free-standing Facilities1

UHC Choice
Network Hospitals1

Office Visits

$30 copay for PCP; $50 copay for specialist

Maternity Office Visits

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

Inpatient Hospital Care

10% after deductible

70% after deductible

Virtual Visits 

$0

Emergency Room

$100 copay, then 10% after deductible

Urgent Care Center

$50 copay

Outpatient Surgery1

Office visit copay applies;
10% after deductible if not in doctor’s office

70% after deductible if not in doctor’s office

Routine Physicals3

$0

Well-Woman/Man Exams (Including Pap Test or PSA Test)3

$0

Well-Child Care (Including Immunizations)3

$0 for first visit of the year, $30 copay for additional visits during the year

Colonoscopy3

$0

Mammography4

$0

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

70% after deductible

MRI, CT & PET Scans1

10% after deductible

70% after deductible

Outpatient Therapy5

$30 per visit

$50 per visit

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 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 co-insurance would be.

2 Maximum includes deductible and copays for medical care and prescriptions. It does 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 each covered up to 20 visits. Up to 36 cardiac rehabilitation visits are covered.