2018 SSA - Medical Plan Comparison Chart

The Medical Plan Comparison Chart below summarizes the Plan provisions. For detailed information, please review the Summary of Benefits and Coverage (SBC) and Summary Plan Description (SPD).

 

Medical Comparison Chart

BenefitChoice In-NetworkChoice Plus 90
 In-NetworkOut-of-NetworkIn-NetworkOut-of-Network
Annual Deductible
(per person)
 N/AN/A$200$600
Coinsurance
(% paid by CU)
100%N/A90% after deductible60% after deductible
Out-of-Pocket Maximum
(Individual)
$3,500N/A$2,500$4,500
Out-of-Pocket Maximum
(Family)
$7,000N/A$5,000$9,000
Preventive Care100%N/A100%Not covered
Physician Office Visits,
including specialists
$30 copayN/A$30 copay60% after deductible
Laboratory/Radiology
Services, including services rendered in a physician's office

100% if non-hospital location; $150 copay if hospital**
N/A90% after deductible60% after deductible
Inpatient Hospital Care$500 copay per admissionN/A90% after deductible60% after deductible;
Precertification required
Outpatient Hospital Care$150 copay (including lab and radiology)**N/A90% after deductible60% after deductible;
Precertification required
Mental Health and Substance Abuse – Inpatient care$500 copay per admissionN/A90% after deductible60% after deductible;
Precertification required
Mental Health and Substance Abuse –Outpatient
programs
$30 copayN/A$30 copay70% after deductible for facility based care, including intensive outpatient programs; Precertification required
Mental Health and Substance Abuse – Outpatient
Counseling
$30 copayN/A$30 copay70% after deductible
Emergency Room$150 copay (waived if admitted)$150 copay (waived if admitted)$150 copay (waived if admitted)$150 copay (waived if admitted)
Basic and Comprehensive Infertility TreatmentUnlimited benefit for diagnosis and basic
medical treatment, including artificial
insemination
N/AUnlimited 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 ZIFTN/A$30,000 lifetime maximum for advanced treatments and Assisted Reproductive Technology including IVF, GIFT and ZIFT
Prescription Drug
coverage with OptumRx

Retail (30-days)
• Generic: $10 copay
• Single-source brand: $25 copay
• Multi-source brand: $45 copay

Mail-order (90-days)
• Generic: $15 copay
• Single-source brand: $50 copay
• Multi-source brand: $90 copay

N/A
Retail (30-days)
• Generic: $10 copay
• Single-source brand: $25 copay
• Multi-source brand: $45 copay
 
Mail-order (90-days)
• Generic: $15 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.
** No copay for Lab and Radiology at certain designated NYP locations. See the list of NYP participating locations.

Remember: The in-network deductible, coinsurance and medical and prescription copays accumulate toward the in-network out-of-pocket maximum. In addition, in the Choice Plus 90 plan only, out-of-network out-of-pocket expenses accumulate toward the in-network out-of-pocket maximum.

 

Important NotesImportant 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.