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

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 (877) 609 - 2273 or contact the Benefits Team at 258 - 3302 for more details. 
 
Compare the rates for this and each plan offered. The Prescription Drug Program is included with this plan.

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.
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
Coinsurance (Out - of - pocket expense)
The percentage of medical expenses shared by you and the plan after you meet your deductible.
10% after deductible
20% after deductible2
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
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
Lifetime Maximum
Medical/surgical/mental health
Unlimited
Unlimited

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 -  and post - partum care inclusive to the surgical charge for delivery

 $25 copayment per office visit
20% after deductible2
Physician Services Performed in a Hospital/Ambulatory Setting
10% after deductible
20% after deductible2 (surgical fees subject to R&C limits)
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
$25 copayment per office visit
20% after deductible
 
 
Scheduled Immunizations
$25 copayment per office visit
20% after deductible2
Inpatient Hospital Services3
 Medical/surgical care (includes maternity)
10% after deductible
20% after deductible2
Urgent Care Facility
$25 copayment per office visit
20% after deductible2
Emergency Room Care
Services administered for conditions meeting the definition of an emergency.
 
You must follow the instructions on your member ID card.
$60 copayment per emergency visit
 
If you are admitted, copayment is waived.
Surgery (Inpatient3/Outpatient)
Anesthesia and use of an operating room or related facility in a hospital or authorized institution
10% after deductible
20% after deductible2
Outpatient Lab and X-Ray Services for Diagnosis or Treatment
10%
20% after deductible2
Outpatient Mental Health and Substance Abuse
Outpatient treatment; crisis intervention; detoxification
$25 copayment per office visit
20% (no deductible required)
Inpatient Mental Health and Substance Abuse3
 
10% after deductible
20% after deductible2
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
20% after deductible2
Chiropractic Services
20 visits per calendar year limit, (combined in -n etwork/out - of -n etwork)
$25 copayment per office visit
20% after deductible2
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
20% after deductible2
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
20% after deductible2
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
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
20% after deductible2
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
Hearing Exam
1 exam per calendar year; 
Coinsurance, deductible or copayment will apply.
$25 copayment per office visit
20% after deductible2
Hearing Aids
Combined in-network/out-of-network limit of $1,500 reimbursement every 3 years
Covered at 100% up to $1,500
Covered at 100% up to $1,500
Routine Eye Exam/Prescription Glasses or Contact Lenses
Not covered
Not covered

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

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
 
If you are a participating retiree, the salary used is your salary at the time of retirement.
 
Only medically necessary services are covered.
 
For information about these plan benefits please call Member Services Toll Free at (877) 609 - 2273.  

PPO Plan Member Information

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. If you would like additional cards, you must contact UnitedHealthcare directly.
 
Use the UnitedHealthcare ID card used to access medical care. You will receive a separate ID card for the Prescription Drug Plan, administered through Medco Health.
 
If a doctor's office and/or hospital needs to verify coverage, they can call the Office of Human Resources at 258 - 3302 or you may provide them with the following information. 
 
Group number
196484
Member ID #
Will be system generated
Phone number
(877) 609 - 2273
 
 
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!
 
 
While the University intends to continue each of the benefit plans, the University reserves the right to terminate or amend any plan, at any time, and for any reason.