1 Maximum includes deductible, co-insurance, and copays for medical care and prescriptions.

2 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 to make sure they are in-network. Check with your insurance carrier to verify whether a facility and/or doctor is covered under your plan and to learn how much your coinsurance would be.

3 Well 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.

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 and rehabilitation services are covered up to 20 visits. Up to 36 cardiac rehabilitation visits are covered.

6 For the purposes of HSA enrollment, Employee + Family coverage includes Employee + Spouse, Employee + Children, or Employee + Family coverage.

7  If you have a medical condition that requires care at a facility that is not on the Preferred Hospital list, contact UnitedHealthcare PRIOR to receiving care/treatment. If expertise is limited at the facilities on the Preferred Hospital list, meaning you are not able to get treatment at a Preferred Hospital, your benefits may be pre-approved to be paid as though you had used a Preferred Hospital (ie: your benefits may pay at a higher level, lowering your cost for services). However, this only applies if UnitedHealthcare pre-approves the covered services/supplies for the condition to be provided by or arranged by a designated facility/other provider not on the Preferred Hospital list. The pre-approval by UnitedHealthcare must be completed prior to care being received. If you have any questions or issues, please contact Benefits Support at 1-877-698-4754 prompt 9.

8 The UHC Choice Plan 1500 option has a non-embedded deductible. This means the family deductible must be paid out of pocket before the plan starts paying for health care services for any individual member.