17
HEALTH PLANS COMPARISON
$1,500 Deductible Health Plan $3,000 Deductible Health Plan
In-network Out-of-network In-network Out-of-network
$250
plus deductible
and coinsurance
You pay 50%
after deductible
$250
plus deductible
and coinsurance
You pay 30%
after deductible
You pay 60%
after deductible
You pay 30%
after deductible
Benefits Department • 800-562-6210, ext. 2495
$1,500 Individual
$3,000 Family
$3,000 Individual
$6,000 Family
$3,000 Individual
$6,000 Family
$6,000 Individual
$12,000 Family
20% 50% 30% 60%
$3,500 Individual
$7,000
2 Individuals
$9,300
3 or more
Individuals
$7,000 Individual
$14,000
2 Individuals
$18,600
3 or more
Individuals
$6,000 Individual
$12,000 Family
$12,000 Individual
$24,000 Family
100% covered You pay 50%
after deductible
100% covered You pay 60%
after deductible
You pay 20%
after deductible
You pay 50%
after deductible
You pay 30%
after deductible
You pay 60%
after deductible
$250
plus deductible
and coinsurance
Deductible
Coinsurance
Out-of-Pocket Maximum
Preventive Care
Well-Child Care to Age 7
Routine Preventive Care or
Biometric Screening - Age 7 and Up
Immunizations Child/Adult
Mammogram, Pap Smear,
Cholesterol and Blood Sugar
Screening, Colonoscopy
Doctor’s Office Visits
Primary Care Consult and
Physician Services
(includes allergy treatment)
Specialist Office Visits
Surgery Performed in
Physician’s Office
Other Services
Emergency Room Visit
Other Emergency Services
Inpatient Hospital Services
Outpatient Facility Services
Urgent Care Services
Mental Health and Substance
Abuse Treatment/Outpatient
Maternity Care
Hospital Charges
Bariatric Surgery
(requires prior UHC approval)
You pay 20%
after deductible
Your doctor may be required to demonstrate medical necessity for certain types of procedures or care options.
$250
plus deductible
and coinsurance
You pay 20% N/A N/A
after deductible