2015 UnitedHealthcare Silver Choice Plus HSA Offered by UnitedHealthcare through Access Health CT Plan Overview In-Network (INET) Member Pays Deductible Individual Family Out-of-Pocket Maximum Individual Family (Includes deductible, copayments and coinsurance) Physician Office Visits Out-of-Network (OON) Member Pays $2,000 per member $4,000 per family $5,000 per member $10,000 per family $5,000 per member $10,000 per family $10,000 per member $20,000 per family Primary Care (Includes services for illness, injury, follow-up care and consultations) $30 copayment per visit after INET deductible is met 30% coinsurance per visit after OON deductible is met 30% coinsurance per visit after OON deductible is met Specialist $45 copayment per visit after INET deductible is met 30% coinsurance per visit after OON deductible is met $75 copayment per visit after INET deductible is met $150 copayment per visit after INET deductible is met $0 copayment after INET deductible is met 30% coinsurance per visit after OON deductible is met $150 copayment per visit after INET deductible is met $0 copayment after INET deductible is met $500 copayment per stay after INET deductible is met $0 copayment per visit after INET deductible is met $500 copayment per stay after INET deductible is met 30% coinsurance per visit after OON deductible is met 30% coinsurance per visit after OON deductible is met 30% coinsurance per visit after OON deductible is met Preventive Care/Screenings/Immunizations $0 Emergency/Urgent Care Urgent Care Center or Facility Emergency Room Ambulance Hospital Services Inpatient Outpatient (performed at hospital or ambulatory facility) Skilled Nursing Facility 90 days plan year maximum Mental Health, Substance Abuse & Behavioral Health Care Mental Health, Substance Abuse & Behavioral Health Services Hospice Care Hospice Services Covered same as any other illness $500 copayment per stay after INET deductible is met Covered same as any other illness 30% coinsurance per visit after OON deductible is met Outpatient Services Home Health Care 100 visits plan year maximum Advanced Radiology (CT/PET Scan, MRI) Non-Advanced Radiology (X-ray, Diagnostic) Laboratory Services Chiropractic Care 20 visits plan year maximum $0 copayment per visit after INET deductible is met $0 copayment per visit after INET deductible is met $0 copayment per visit after INET deductible is met $0 copayment per visit after INET deductible is met $45 copayment per visit after INET deductible is met 30% coinsurance per visit after OON deductible is met 30% coinsurance per visit after OON deductible is met 30% coinsurance per visit after OON deductible is met 30% coinsurance per visit after OON deductible is met 30% coinsurance per visit after OON deductible is met This Plan Design sample is representative and is not intended to be a legal contract. Please see the actual plan documents for a full list of benefit coverage, exclusions and the terms of the policy. Page 1 11/12/2014 2015 UnitedHealthcare Silver Choice Plus HSA Offered by UnitedHealthcare through Access Health CT Plan Overview Outpatient Services Speech Therapy 40 visits per plan year limit combined for physical, occupational, rehabilitative & habilitative therapy Physical, Occupational, Rehabilitative & Habilitative Therapy 40 visits per plan year limit combined for speech therapy Other Services Durable Medical Equipment Prosthetics Diabetic Supplies & Equipment Prescription Drugs Tier 1 Tier 2 Tier 3 Pediatric-Only Services (for children under age 19) Pediatric Dental Care Diagnostic & Preventive (Oral Exam, Cleaning, X-ray) 1 visits limit per six (6) months-applies to In-Network and Out-of-Network) Basic Restorative (Filling, Simple Extraction) Major Restorative (Endodontic, Crown) Orthodontia Services Medically necessary only Pediatric Vision Care Routine Eye Exam by Specialist One exam per plan year Prescription Eye Glasses One pair of frames & lenses per plan year In-Network (INET) Member Pays Out-of-Network (OON) Member Pays $45 copayment per visit after INET deductible is met 30% coinsurance per visit after OON deductible is met $30 copayment per visit after INET deductible is met 30% coinsurance per visit after OON deductible is met $0 copayment per DME item after INET deductible is met $0 copayment after INET deductible is met $0 copayment per equipment/supply after INET deductible is met 30% coinsurance per DME item after OON deductible is met 30% coinsurance after OON deductible is met 30% coinsurance per equipment/supply after OON deductible is met $5 copayment per prescription after INET deductible is met $40 copayment per prescription after INET deductible is met 50% coinsurance per prescription after INET deductible is met up to $500 maximum per prescription $5 copayment per prescription after INET deductible is met $40 copayment per prescription after INET deductible is met 50% coinsurance per prescription after INET deductible is met up to $500 maximum per prescription $0 0% coinsurance per visit after OON deductible is met 20% coinsurance per visit after INET deductible is met 50% coinsurance per visit after INET deductible is met 50% coinsurance per visit after INET deductible is met 20% coinsurance per visit after OON deductible is met 50% coinsurance per visit after OON deductible is met 50% coinsurance per visit after OON deductible is met $30 copayment per visit after INET deductible is met 50% coinsurance per visit after OON deductible is met Lenses: 50% coinsurance after INN deductible is met Collection Frame: 50% coinsurance after INN deductible is met Non-collection frame: Members choosing to upgrade from a collection frame to a noncollection frame will be given a credit substantially equal to the cost of the collection frame and will be entitled to any discount negotiated by the carrier with the retailer. 50% coinsurance after OON deductible is met This Plan Design sample is representative and is not intended to be a legal contract. Please see the actual plan documents for a full list of benefit coverage, exclusions and the terms of the policy. Page 2 11/12/2014
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