UnitedHealthcare

UHC Gold Value+ ($3 Rx)

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Plan Overview

Combined Medical and Drug Deductible	Individual: $2,250 Family: $4,500 Per Person: $2,250
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: Not Applicable CoInsurance: 20% Coinsurance after deductible Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Limit Quantity: 30 Limit Unit : Days per Month Benefit Explanation: 90-day supplies available at a Preferred Retail Pharmacy or Home Delivery. Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 30% Coinsurance after deductible Covered: Covered Limit Quantity: 30 Limit Unit : Days per Month Benefit Explanation: 90-day supplies available at a Preferred Retail Pharmacy or Home Delivery. Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply.
Generic Drugs	CoPay: $3.00 CoInsurance: Not Applicable Covered: Covered Limit Quantity: 30 Limit Unit : Days per Month Benefit Explanation: See SBC for Non-Preferred Pharmacy Cost Share and (non-preferred) Generic Cost Share. 90-day supplies available at a Preferred Retail Pharmacy or Home Delivery. Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 40% Coinsurance after deductible Covered: Covered Limit Quantity: 30 Limit Unit : Days per Month Benefit Explanation: Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 20% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 20% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 20% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: No Charge Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year

Major Dental Care

Routine Dental Checkups for Children	CoPay: Not Applicable CoInsurance: No Charge Covered: Covered Limit Quantity: 1 Limit Unit : Visit(s) per 6 Months
Routine Dental Checkups for Adults	Covered: Not Covered
Basic Dental Care - Adult	Covered: Not Covered
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 20% Coinsurance after deductible Covered: Covered Benefit Explanation: Benefit limitations may apply to individual services.
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 20% Coinsurance after deductible Covered: Covered Benefit Explanation: Benefit limitations may apply to individual services.

Medical plan coverage offered by: UnitedHealthcare of Arizona, Inc.; Rocky Mountain Health Maintenance Organization, Incorporated in CO; UnitedHealthcare of Florida, Inc.; UnitedHealthcare of Georgia, Inc.; UnitedHealthcare of Illinois, Inc.; UnitedHealthcare Insurance Company in LA, TN and AL; Optimum Choice, Inc. in VA and MD; UnitedHealthcare Community Plan, Inc. in MI; UnitedHealthcare of North Carolina, Inc.; UnitedHealthcare of Oklahoma, Inc.; UnitedHealthcare of Texas, Inc.; and UnitedHealthcare of Oregon, Inc. in WA. Administrative Services provided by United HealthCare Services, Inc. or their affiliates.

Plan specifics and benefits may vary by coverage area and by plan category. Please review the plan details to learn more. This policy has exclusions, limitations, reduction of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable). By responding to this offer, you agree that a representative may contact you.

You are required to select a Primary Care Physician (PCP) within our network. Your PCP refers you to specialists when necessary. If you use a specialist without a referral or see a provider who is not in your network, you may have to pay the full cost of the benefits and services. Emergency services received by an out-of-network provider are covered.

Health Maintenance Organization, Inc. in Colorado and UnitedHealthcare Insurance Co. in Tennessee. Administrative Services provided by United HealthCare Services, Inc. or their affiliates.

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