UnitedHealthcare Choice Plus (PPO)
This UnitedHealthcare Plan is not available to you if you are a non - U.S. citizen on a J - 1 Visa.
The UnitedHealthcare Choice Plus (PPO) Plan has both an in-network and out-of-network component. It has no exclusions for preexisting conditions.
The in - network approach allows members to seek care without having to designate a primary care physician. As a result, it is not necessary to obtain a referral before visiting another physician or specialist.
The out - of - network portion of the plan provides the participant with the ability to see any physician at a greater cost.
For a current Physician Directory, visit UnitedHealthcare's website. Choose "Find Physicians and Facilities" in the center of the page. At "Select a Product," use the drop-down menu to select the plan UnitedHealthcare Choice Plus network and complete the search.
Plan Overview
Plan Provision |
In-Network Service |
Out-of-Network Service |
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Deductible
The amount you pay each year before the plan begins covering particular medical expenses. Family deductible is cumulative. |
Individual: $300
Family: $600 In - network/out - of - network deductible cross applies1
|
Individual: $600
Family: $1,200 In - network/out - of - network deductible cross applies1
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Coinsurance (Out - of - pocket expense)
The percentage of medical expenses shared by you and the plan after you meet your deductible. |
10% after deductible
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20% after deductible2
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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 eligible medical expenses, including your deductible and coinsurance; excludes copayments |
See Salary Band Chart below for in - network/out - of - network coinsurance limit cross applies1
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| Non-Notification/Non-Compliance Penalty The amount you must pay if you do not call Medical Management at (877) 609-2273 before hospitalization and certain types of surgery, or fail to follow concurrent review procedures. |
$200 per procedure and/or admission |
$200 per procedure and/or admission |
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Lifetime Maximum
Medical/surgical/mental health |
Unlimited
|
Unlimited
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Feature/Service |
In-Network Service: You Pay |
Out-of-Network Service: You Pay |
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Physician Services Performed in an Office Setting |
$25 copayment per office visit
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20% after deductible2
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Physician Services Performed in a Hospital/Ambulatory Setting
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10% after deductible
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20% after deductible2 (surgical fees subject to R&C limits)
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Preventive Care
Preventive physicals, well - child care (including scheduled immunizations), Plan pays for up to seven visits during first year for well-child care, PSA, PAP tests, and well - woman care office visits
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$25 copayment per office visit
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20% after deductible
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Scheduled Immunizations
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$25 copayment per office visit
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20% after deductible2
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Inpatient Hospital Services3
Medical/surgical care (includes maternity) |
10% after deductible
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20% after deductible2
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| Urgent Care Facility |
$25 copayment per office visit
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20% after deductible2
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Emergency Room Care
Services administered for conditions meeting the definition of an emergency. You must follow the instructions on your member ID card.
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$60 copayment per emergency visit
If you are admitted, copayment is waived.
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Surgery (Inpatient3/Outpatient)
Anesthesia and use of an operating room or related facility in a hospital or authorized institution |
10% after deductible
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20% after deductible2
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Outpatient Lab and X-Ray Services for Diagnosis or Treatment
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10%
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20% after deductible2
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Outpatient Mental Health and Substance Abuse
Outpatient treatment; crisis intervention; detoxification |
$25 copayment per office visit
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20% (no deductible required)
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Inpatient Mental Health and Substance Abuse3
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10% after deductible
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20% after deductible2
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Outpatient Physical Rehabilitation
Short - term physical, speech, occupational or pulmonary and cardio rehabilitation therapies Maximum of 50 visits per therapy per calendar year (combined in - network/out - of - network)
|
10% after deductible
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20% after deductible2
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Chiropractic Services
20 visits per calendar year limit, (combined in -n etwork/out - of -n etwork) |
$25 copayment per office visit
|
20% after deductible2
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Home Health Care
Services provided in the home by an RN, LPN or contract therapist 60 visits per calendar year limit (combined in - network/out - of - network) |
10% after deductible
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20% after deductible2
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Skilled Nursing Facility/Inpatient Physical Rehabilitation
Confinement and skilled nursing services in a hospital or specialized facility 60 days per calendar year limit (combined in - network/out - of - network) |
10% after deductible
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20% after deductible2
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Hospice Care
Room and board in a licensed facility or in your home; services of medical personnel; others services and supplies 180 day maximum (combined in - network/out - of -n etwork) |
Inpatient: 10% after deductible
Outpatient: 10% after deductible
|
Inpatient: 20% after deductible2
Outpatient: 20% after deductible2
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Durable Medical Equipment Purchase or Rental
Splints, braces, nonsurgically implanted prostheses, specified medical equipment for use in the home $50,000 lifetime maximum (In-network/out - of - network) |
10% after deductible
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20% after deductible2
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Nutritional Counseling
Limited to 3 visits per calendar year with referral and/or script by your physician; coinsurance, deductible, or copay will apply |
$25 copayment per office visit
|
20% after deductible2
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Hearing Exam
1 exam per calendar year; Coinsurance, deductible or copayment will apply.
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$25 copayment per office visit
|
20% after deductible2
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Hearing Aids
Combined in-network/out-of-network limit of $1,500 reimbursement every 3 years |
Covered at 100% up to $1,500
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Covered at 100% up to $1,500
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Routine Eye Exam/Prescription Glasses or Contact Lenses
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Not covered
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Not covered
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1The 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.
2You pay 20% after you meet the required deductible and any amounts over reasonable and customary; the plan will pay 80% of reasonable and customary after you meet the required deductible.
3These services require pre-certification through UnitedHealthcare. You must call UnitedHealthcare at (877) 609-2273 at least 14 days in advance of nonemergency treatment to request precertification or you will have to pay a $200 penalty per procedure and/or admission.
Salary Band Chart
Find the salary range below which includes your January 1 (or salary at date of hire, if later) base salary to determine your in-network and/or out-of-network coinsurance limit.
Base Salary Range |
In-Network Coinsurance Limit |
Out-of-Network Coinsurance Limit |
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From
|
To
|
Individual
|
Family
|
Individual
|
Family
|
|
$0 -
|
$24,999
|
$ 800
|
$1,600
|
$1,600
|
$ 3,200
|
|
25,000
|
39,999
|
1,000
|
2,000
|
2,000
|
4,000
|
|
40,000
|
54,999
|
1,800
|
3,600
|
3,600
|
7,200
|
|
55,000
|
74,999
|
2,400
|
4,800
|
4,800
|
9,600
|
|
75,000
|
94,999
|
3,600
|
7,200
|
7,200
|
14,400
|
|
95,000
|
119,999
|
4,400
|
8,800
|
8,800
|
17,600
|
|
120,000
|
159,999
|
5,200
|
10,400
|
10,400
|
20,800
|
|
160,000
|
199,999
|
5,900
|
11,800
|
11,800
|
23,600
|
|
200,000
|
& Over
|
7,600
|
15,200
|
15,200
|
30,400
|
PPO Plan Member Information
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Group number
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196484
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Member ID #
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Will be system generated
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Phone number
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(877) 609 - 2273
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You can count on support from knowledgeable and responsive HR staff when you have a benefits question or problem. Just call or e-mail us. We’re here to help!