Summary Plan Description

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United Healthcare Out of Area (PPO) Plan Benefits
Option 1

For information about these plan benefits or help enrolling, please call the plan office at 1-888-880-8BAC

Plan Provision	*Network Service You Pay**	Non-Network ServiceYou Pay
Deductible – The amount you pay each year before the plan begins covering your medical expenses. (This does not apply to services for which you pay a copayment)	Individual - $5,000 Family - $1,000	Individual - $10,000 Family - $20,000
Coinsurance – The percentage of medical expenses shared by you and the plan after you meet your deductible.	Plan pays 80% after deductible	Plan pays 60% after deductible
Hospital Confinement Copayment/Deductible – The amount you pay out-of-pocket each time you are confined to a hospital, skilled nursing facility or inpatient rehabilitation facility.	Plan pays 80% after deductible	Plan pays 60% after deductible
Outpatient Surgery Copayment – The amount you pay for each outpatient surgery.	Plan pays 80% after deductible	Plan pays 60% after deductible
Out-of-Pocket – Total amount you pay out-of-pocket in one calendar year before the plan pays 100% of eligible charges.	Individual - $10,000 Family - $20,000	Individual - $20,000 Family - $40,000
Non-Notification – The amount you must pay if you do not call Medical Management when required.	Does not apply.	$500 per procedure, admission or date of service, and reduction to 50% benefit

Feature / Service	Network Service You Pay	Non-Network ServiceYou Pay
Physician Services Office visits for routine care; diagnosis and treatment of an illness or injury.	$25 per PCP office visit $50 per specialist office visit	Plan pays 20% after deductible
Preventive Care Periodic checkups, annual physicals, well-child care, immunizations, mammography and well-woman care.	$20 per office visit No copay for mammogram	Not covered
Inpatient Hospital Services Semi-private room and board charges, intensive care, cardiac care, etc.	Plan pays 80% after deductible	Plan pays 20% after deductible
Emergency Room Care Services administered for conditions meeting the definition of an emergency.	$200 per emergency visit for all medically necessary treatment. If you are admitted, copayment is waived and you must call your PCP within 2 working days of admission.
Urgent CareCenter Services administered for conditions requiring immediate care when your PCP is not available, or after normal office hours.	$50 per visit	Plan pays 60% after deductible
Surgery Anesthesia and use of an operating room or related facility in a hospital or authorized outpatient center.	Plan pays 80% after deductible	Plan pays 60% after deductible
Lab and X-Ray Services X-rays or laboratory tests for diagnosis or treatment.	Plan pays 80% after deductible	Plan pays 60% after deductible
Outpatient Physical Rehabilitation Short-term physical, occupational or speech therapies.	$50 per office visit Limit of 20 visits per calendar year	Plan pays 60% after deductible (combined network/non-network)
Home Health Care Services provided in the home by an RN, LPN or contracted therapist.	Plan pays 80% after deductible 40 days per calendar year limit	Plan pays 60% after deductible (combined network/non-network)
Skilled Nursing Facility/ Inpatient Physical Rehabilitation Confinement for skilled nursing services in a hospital of specialized facility.	Plan pays 100% 120 days per calendar year limit	Plan pays 60% after deductible (combined network/non-network)
Hospice Care Room and board in a licensed facility or services of medical personnel in your home.**.	Plan pays 80% after deductible	Plan pays 60% after deductible
Durable Medical Equipment Splints, braces, non-surgically implanted prostheses, specified medical equipment for use in the home.	Plan pays 80% after deductible	Plan pays 60% after deductible Authorization required if over $300
Managed Mental Health and Substance Abuse Outpatient short-term evaluation; crisis intervention; alcohol or drug detoxification; medical complication of chemical dependency.	25% (Plan pays 75%)	60% after deductible
Managed Mental Health and Substance Abuse Inpatient treatment in a hospital or residential treatment center.	Plan pays 80% after deductible	60% after deductible

Feature / Service	United HealthCare Transplant Benefit Management Program You Pay	Network ServiceYou Pay	Non-Network ServiceYou Pay
Select Organ and Tissue Transplants Physician visits, impatient surgery, and confinement in a hospital. (Voluntary URN)	Nothing (Plan pays 100%) Plan pays $10,000 lifetime maximum	See appropriate category above 100% (Plan pays $0)	See appropriate category above 100% (Plan pays $0)

*You may also be charged the Hospital Confinement Deductible if these services are performed while you are confined to the hospital

** Must have prior approval of Medical Management.

Only medically necessary services are covered .

This is a general summary of your benefits. A more complete description of your benefits and the terms under which they are provided, including limitations and exclusions are contained in the plan documents. If there are any discrepancies between the information contained in this comparison of plan benefits and the provisions of the plan documents, the plan documents are the controlling documents.

Like most group medical plans and insurance policies, this plan contains certain exceptions, waiting periods, reductions, limitations and terms. Ask you group representative for complete details.

United Healthcare Out of Area (PPO) Plan Benefits Option 1

United Healthcare Out of Area (PPO) Plan Benefits
Option 1