NUSS - Medical Plan Summary 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 Coverage

BenefitChoice Plus 100
Annual Deductible (per person) N/A$600
Coinsurance (% paid by the Plan)100%60% after deductible
Out-of-Pocket Maximum (Individual)$3,500$4,000
Out-of-Pocket Maximum (Family)$7,000$8,000
Preventive Care100%Not covered
Physician Office Visits, including specialists$30 copay60% after deductible
Laboratory/Radiology Services, including services rendered in a physician’s office100% if non-hospital location; $150 copay if hospital**

60% after deductible

Inpatient Hospital Care$500 copay per admission60% after deductible;
precertification required
Outpatient Hospital Care$150 copay (including lab and radiology**)60% after deductible;
precertification required
Mental Health and Substance Abuse – Inpatient care$500 copay per admission60% after deductible;
Precertification required
Mental Health and Substance Abuse – Outpatient programs$30 copay70% after deductible for facility
based care, including intensive outpatient programs; precertification required
Mental Health and Substance Abuse – Outpatient Counseling$30 copay70% after deductible
Emergency Room 
$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
Advanced Infertility Treatment$30,000 lifetime maximum for advanced treatments
and Assisted Reproductive Technology
including IVF, GIFT and ZIFT
Prescription Drug coverage with OptumRxRetail (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 at


Remember: The medical and prescription drug copays accumulate toward the in-network out-of-pocket maximum. In addition, out-of-network out-of-pocket expenses accumulate toward the in-network out-of-pocket maximum.

ImportantImportant 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.