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N/A = Not Applicable

	UnitedHealthcare Choice Plus POS		UnitedHealthcare Options PPO Plan		UnitedHealthcare Select EPO
Medical	Network	Non Network	Network	Non Network	Network	Non Network
Deductible
Employee	None	$125	None	$125	None	N/A
Family	None	$250	None	$250	None	N/A
Out-of-pocket maximum
Employee	$500	$1,500	$500	$1,500	None	N/A
Family	$1,000	$3,000	$1,000	$3,000	None	N/A
Office / Doctor visit	$15 copay	70% after deductible	$15 copay	70% after deductible	$15 copay	N/A
Specialist visit	$30 copay	70% after deductible	$30 copay	70% after deductible	$30 copay	N/A
Urgent care visit	$30 copay	70% after deductible	$30 copay	70% after deductible	$30 copay	N/A
Emergency room	$75 for facility / $75 ER Physician ($75 Copay ER Facility, waived if admitted / $75 Copay for ER Physician, waived if admitted / For Non Emergency Diagnoses: 50% Coinsurance plus 2 $75 Copays)		$75 for facility / $75 ER Physician ($75 Copay ER Facility, waived if admitted / $75 Copay for ER Physician, waived if admitted / For Non Emergency Diagnoses: 50% Coinsurance plus 2 $75 Copays)		$75 for facility / $75 ER Physician ($75 Copay ER Facility, waived if admitted / $75 Copay for ER Physician, waived if admitted / For Non Emergency Diagnoses: 50% Coinsurance plus 2 $75 Copays)	N/A
Ambulance	100% for Medical Emergency / 90% for Non-Medical Emergency	100% for Medical Emergency / 70% for Non-Medical Emergency	100% for Medical Emergency / 90% for Non-Medical Emergency	100% for Medical Emergency / 70% for Non-Medical Emergency	100%	N/A
Outpatient surgery	90%	70% after deductible	90%	70% after deductible	100%	N/A
Lab and X-ray	90%	70% after deductible	90%	70% after deductible	100%	N/A
Hospital stay	90%	70% after deductible	90%	70% after deductible	100%	N/A
Maternity Stay	90%	70% after deductible	90%	70% after deductible	100%	N/A
Well-child visits	100%	Not Covered	100%	70% after deductible	100%	N/A
Mammogram	100% for routine preventive / 90% for diagnostic mammogram	70% after deductible	100% for routine preventive / 90% for diagnostic mammogram	70% after deductible	100%	N/A
Annual adult physical	100%	Not Covered	100%	70% after deductible	100%	N/A
Acupuncture for Chronic Pain Mgmt	90%	70% after deductible	$20 copay	70% after deductible	100%	N/A
Chiropractic	90%	70% after deductible	$20 copay	70% after deductible	100%	N/A
Hearing Aid Exam	$15 / $30	Children Under Age 19 Only - 70% after deductible	$15 / $30	70% after deductible	$15 / $30	N/A
Hearing Aids ($5,000 Max per ear every 36 months)	100% for standard hearing aid	Adult hearing aids not covered 70% for children under 19	100% for standard hearing aid	70% after deductible	100% for standard hearing aid	N/A
DME	90%	70% after deductible	90%	70% after deductible	100%	N/A
PT/OT/SP	$30 copay	70% after deductible	$30 copay	70% after deductible	$30 copay	N/A
Vision Plan	See Vision Plan		See Vision Plan		See Vision Plan	N/A

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