The Medical Plan Summary Chart below summarizes the Choice Plus 80 plan provisions:
Medical Plan Summary
Choice Plus 80
$850 per person
|Coinsurance (% paid by the Plan)||80% after deductible||60% after deductible|
|Preventive Care||100%||Not covered|
|Physician Office Visits, including specialists||$30 copay||60% after deductible|
|Laboratory/Radiology Services, including services rendered in a physician’s office||80% after deductible||60% after deductible|
|Inpatient Hospital Care||80% after deductible||60% after deductible; Precertification required|
|Outpatient Hospital Care||80% after deductible||60% after deductible; Precertification required|
|Mental Health and Substance Abuse – Inpatient care||80% after deductible||60% after deductible; Precertification required|
|Mental Health and Substance Abuse – Outpatient programs||$30 copay||70% after deductible for facility based care, including intensive|
outpatient programs; Precertification required
|Mental Health and Substance Abuse – Outpatient Counseling||$30 copay||70% after deductible|
|Emergency Room ||$150 copay (waived if admitted)||$150 copay (waived if admitted)|
|Basic and Comprehensive Infertility Treatment||Unlimited benefit for diagnosis and basic medical treatment, including artificial insemination|
|Advanced Infertility Treatment||$30,000 lifetime maximum for advanced treatments and Assisted Reproductive Technology including IVF, GIFT and ZIFT|
|Prescription Drug coverage with OptumRx||Retail (30-days)|
• Single-source brand: $25 copay
• Multi-source brand: $45 copay
• Single-source brand: $50 copay
• Multi-source brand: $90 copay
*Out-of-Network coinsurance reimbursement is indexed to 190% of the Medical Maximum Allowance Charge (MAC), including expenses in excess of the out-of-network out-of-pocket maximum.
**To meet the requirements of the U.S. Department of State, J-1 Visa holders will have a $500 per person deductible applied.
Remember: In the Choice Plus 80 plan, in-network deductible, coinsurance and medical and prescription drug copays accumulate toward the in-network out-of-pocket maximum. In addition, out-of-network expenses accumulate toward the in-network out-of-pocket maximum.
Important Notes: UHC’s Choice network is a national provider network and does not require a primary care physician or referrals to see specialists. UHC requires precertification for some services. If you use an in-network provider, your participating network physician or hospital generally handles the precertification process. However, it is your responsibility to confirm that your provider has obtained the necessary authorizations from UHC. If you see a provider who is out-of-network, you are responsible for obtaining precertification for most services except routine office visits.