Your Coverage

MEDICAL BENEFIT SYNOPSIS 1 Provider Network 2 Deductible 3 4

Calendar Year Network Non-Network

Janet's Coverage
Network United Choice Plus Calendar Year $2,000 $4,000 $4,000 $8,000 Non-Network

Individual Family

5 6 Health Savings Account (HSA) Are 7 you eligible? Will your employer contribute? 8 9 Employee Coinsurance 10 Plan Coinsurance 11 Max Out-of-Pocket (includes Deductible) 12 13
Calendar Year

No one in the family is eligible for benefits until the family deductible has been met. In and out-of-network deductibles do not cross accumulate. ASHA HSA Contribution $1,000 individual coverage $2,000 individual plus dependent coverage 0% 100% Calendar Year $3,000 $6,000 No copay - Ded, then 0% Ded, then 0% Ded, then 0% Ded, then 0% 0% 0% Ded, then 0% Ded, then 0% $8,000 $16,000 Ded, then 20% Ded, then 20% Ded, then 20% Ded, then 0% Ded, then 20% Ded, then 20% Ded, then 20% 20% 80%

Individual Family

14 Doctor Visit Copay (PCP/Specialist) 15 Convenience Care Centers 16 Urgent Care Center 17 Emergency Room (True Emergency) 18 Preventive Care Services 19 Lab, X-ray and Major Diagnostics 20 Hospital Copay/Deductible: (Precert required?) 21

Pre-certification required for all in-patient stays

22 OutPatient Copay/Deductible:

Ded, then 0% Ded, then 0%

Ded, then 20% Ded, then 20%

Rehabilitation Services: Chiro, PT, OT, SLP 23 may limit # of visits

## Durable Medical Equipment ##

Ded, then 0%

Ded, then 20%

Pre-service notification is required for DME and Diabetes equipment in excess fo $1,000.
Subject to Calendar Year Deductible All Rx Copayments accumulate towards the Out-ofPocket Maximum $10/$35/$60 for 31 day supply $20/$70/$120 for 90 day supply

## Prescription Card Benefit ## ## ##

Retail: Generic/Formulary/NonFormulary Mail Order: