Benefit Explanation: Including doctor visits in the home and online visits. Virtual Primary Care limited to age 18 and older.
Specialist
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: No Charge
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. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-
day supply.
Non Preferred Brand Drugs
CoPay: No Charge
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. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-
day supply.
Generic Drugs
CoPay: No Charge
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. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-
day supply.
Specialty Drugs
CoPay: No Charge
CoInsurance: Not Applicable
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. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-
day supply.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Benefits for room, board, and nursing services include: a room with two or more beds; a private
room when medically necessary for isolation and no isolation facilities are available; a room in an
approved special care unit; meals, special diets; general nursing services; operating, childbirth, and
treatment rooms and equipment; prescribed drugs; anesthesia, anesthesia supplies and services
given by the hospital or other provider; medical and surgical dressings and supplies, casts, and
splints; blood and blood products; diagnostic services. Includes coverage for general anesthesia and
hospitalization services when determined by dentist and treating physician that such services are
required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered
persons who are severely disabled, or (iii) covered persons who have a medical condition that
requires admission to a hospital or Outpatient surgery facility.
Inpatient Services
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes medical care visits; intensive medical care when medically necessary; treatment for a health
problem by a Doctor who is not your surgeon while you are in the Hospital for surgery; treatment by
two or more Doctors during one Hospital stay when the nature or severity of your health problem
calls for the skill of separate Doctors; a personal bedside exam by another Doctor when asked for by
your Doctor; surgery and general anesthesia; professional charges to interpret diagnostic tests such
as imaging, pathology reports, and cardiology.
Surgeries and procedures to correct congenital abnormalities that cause functional impairment and
congenital abnormalities in newborn children; other invasive procedures, such as angiogram,
arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as
arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations;
anesthesia and surgical support when medically necessary; medically necessary pre-operative and
post-operative care.
Medical benefits are limited to certain oral surgeries including: treatment of medically diagnosed
cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related
to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because
of a medical condition or injury or for a physical abnormality that prevents normal function of the
joint or bone and is medically necessary to attain functional capacity of the affected part; oral /
surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth
when the main purpose is not to treat or help the teeth and their supporting structures; treatment of
non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft
tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and
illnesses of the eye.
Emergency and Urgent Care
Emergency Room
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Urgent Care Facility
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: No Charge 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: No Charge 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: No Charge 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.
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.
1-817-813-4562, TTY 711
