UnitedHealthcare Select Plus Point of Service Plan

UnitedHealthcare Select Plus
Point of Service Plan (POS)
Benefit Summary

This plan is NOT available to you if you are a non-U.S. citizen on a J-1 Visa

The Point of Service (POS) Plan features both an In-Network and Out-of-Network component. The In-Network approach requires that members seek care through a primary care physician and features no deductible, no claim forms, and a copayment for office visits. The Out-of-Network portion of the plan provides the participant with the ability to see any physician, but a greater cost. No pre-existing condition exclusion applies.

For a current Physician Directory, visit the UnitedHealthcare's Web site at http://www.myuhc.com/groups/princetonuniversity. At "Select a Product" - choose UnitedHealthcare Select Plus POS from the drop down menu.

The chart below provides a brief overview of the benefits offered. Please review the UnitedHealthcare Plan package, call UnitedHealthcare for Princeton University toll free at 1-877-609-2273, or call the Office of Human Resources at 609-258-3302 for more details

Plan Provision	In-Network Service	Out-of-Network Service
Deductible The amount you pay each year before the plan begins covering particular medical expenses. Family deductible is cumulative.	Not applicable	Individual - $ 900 Family - $1,800
Coinsurance (Out-of-pocket expense) The percentage of medical expenses shared by you and the plan after you meet your deductible.	The plan pays 100% after you pay the required copay or 10%	30% after deductible*
Coinsurance Limit (Maximum out-of-pocket expense) Total amount you pay out-of-pocket in one calendar year before the plan pays 100% of your medical expenses. (Includes your deductible and coinsurance, but excludes copayments).	Individual - $1,500 Family - $3,000 In-Network/Out-of-Network coinsurance limit cross applies**	Individual - $4,500 Family - $9,000 In-Network/Out-of-Network coinsurance limit cross applies**
Lifetime Maximum Medical/Surgical/Mental Health	Unlimited	$2,000,000 limit
Feature/Service	In-Network Service - You Pay	Out-of-Network Service - You Pay
Physician Services Performed in an Office Setting Office visits for routine care; diagnosis and treatment of an illness or injury and initial maternity visit. Pre & post partum care are inclusive to the surgical charge for delivery	$15 copay per Primary Care Physician office visit $20 copay per Specialist office visit	30% after deductible*
Physician Services Performed in a Hospital	10%	30% after deductible*
Physician Services Performed in an Ambulatory Surgical Center	10%	30% after deductible*
Office Based Surgery	$15 copay per Primary Care Physician office visit $20 copay per Specialist office visit	30% after deductible*
Preventive Care Preventive physicals, well-child care (including scheduled immunizations), PSA, PAP tests and well woman care office visits.	$15	Not covered
Scheduled immunizations	$15	Adult Immunizations not covered
Inpatient Hospital Services Medical/Surgical Care (includes maternity).	10%	30% after deductible*
Emergency Room Care Services administered for conditions meeting the definition of an emergency. You must follow the instructions on your member ID card.	$50 copayment per emergency visit for all medically necessary treatment. If you are admitted, copayment is waived.
Surgery (Inpatient) Anesthesia and use of an operating room or related facility in a hospital or authorized institution.	10%	30% after deductible*
Surgery (Outpatient)	No Charge	30% after deductible*
Outpatient Lab and X-Ray Services for Diagnosis or Treatment	No Charge	30% after deductible*
Inpatient Mental Health/Substance Abuse 30 days per calendar year limit (combined In-Network/Out-of-Network.)	10%	30% after deductible*
Outpatient Mental Health/Substance Abuse 50 visits per calendar year limit (combined In-Network/Out-of-Network.)	20%	30% (no deductible required)
Skilled Nursing Facility/ Inpatient Rehabilitation Facility Services Limited to 60 days per calendar year (combined In-network/out-of-network)	10%	30% after deductible*
Outpatient Physical Rehabilitation*** Short-term physical, speech, occupational, or pulmonary and cardio rehabilitation therapies. Maximum of 50 visits per therapy, per calendar year.	$20 copay	30% after deductible*
Chiropractic Services 20 visits per calendar year limit.	$20 copay	30% after deductible*
Nutritional Counseling Limited to 3 visits per calendar year with referral and/or script by your physician; coinsurance, deductible, or copay will apply	$15 copay per Primary Care Physician office visit $20 copay per Specialist office visit	30% after deductible*
Hearing Exam 1 exam per calendar year; coinsurance, deductible, or copay will apply	$15 copay per Primary Care Physician office visit $20 copay per Specialist office visit	30% after deductible*
Hearing Aids Maximum reimbursement of $1,500 every three years	Covered	Covered
Routine Eye Exam/Prescription Glasses or Contact Lenses	Not covered	Not covered

*You pay 30% after you meet the required deductible and any amounts over reasonable and customary; the plan will pay 70% of reasonable and customary after you meet the required deductible.

**The term "cross applies" means that In-Network payments count toward your Out-of-Network payment limits if you decide to use Out-of-Network services. Likewise, Out-of-Network payments count toward your In-Network payment limits if you decide to use In-Network services.

***These services require pre-certification through United Healthcare. You must call UnitedHealthcare at least 14 days in advance of non-emergency treatment to request pre-certification.

Prescription Drug Program - Medco Health

Retail Program (30 day supply)	Mail Order Program (90 day supply)
$5 Copay - Generic drugs $20 Copay - Brand Name drugs $35 Copay - Multi Source drugs*	$10 Copay - Generic drugs $40 Copay - Brand Name drugs $70 Copay - Multi Source drugs*
Deductible: NONE

*Multi Source drugs are Brand Name Drugs for which generics are available. You will pay this copay if you receive the Brand Name.

Point of Service Plan Member Information

You should receive your UnitedHealthcare ID card at the end of December 2008. UnitedHealthcare provides a "family" ID card. Rather than each UnitedHealthcare member receiving an ID card, the "family" will receive two cards with all of the members information listed on them. The ID card should be used to access medical care. If a doctor's office or hospital needs to verify coverage, they can call the Office of Human Resources at 609-258-3302 or you may provide them with the following information:

Plan:	UnitedHealthcare Select Plus POS Plan
Group number:	196484
Member ID#:	Will be system generated
Phone number:	1-877-609-2273

If you need to request additional ID cards, have a question regarding eligibility, policies, or to select a new primary care physician, please call UnitedHealthcare's Service Center for Princeton University toll free at 1-877-609-2273.

You will receive a separate ID card for the prescription drug program administered through Medco Health. If you need to purchase a prescription at a participating retail pharmacy before you receive your ID card, please provide the pharmacist with the following information:

Your Provider:	Medco Health
Member ID #:	Will be system generated
Phone number:	1-800-711-0917

If you do not appear in the system yet, you should pay for your prescription, submit the receipt along with the Medco claim form to Medco Health. The claim form can be obtained from the web at www.princeton.edu/hr or by calling the Office of Human Resources at 609-258-3302.

Last Updated: 06/19/09