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|
| | In-Network | Out-of-Network |
| Deductibles | Total in-network and out-of-network deductibles:
$2,500 per employee
$5,000 per family |
| HSA | The University of Minnesota allocation
which may be used to offset deductible expenses:
$1,000for an employee
$2,000 for a family |
| Emergency Care | 90% after deductible | 70% after deductible |
| Urgent Care | 90% after deductible | 70% after deductible |
| Network Hospital - General | 90% after deductible | 70% after deductible |
| Network Hospital - Mental Health/Chemical Dependency | 90% after deductible | 70% after deductible |
| In-Network Health Care Services |
| Preventive Care | 100% coverage | 70% after deductible |
| Physician | 90% after deductible | 70% after deductible |
| Eye and Hearing Exam (nonroutine) | 90% after deductible | 70% after deductible |
| Outpatient/surgery | 90% after deductible | 70% after deductible |
| Outpatient Mental Health/Chemical Dependency | 90% after deductible | 70% after deductible |
| Chiropractic Care | 90% after deductible | 70% after deductible |
| Physical, Speech, Occupational Therapy | 90% after deductible | 70% after deductible |
| Home Health Care | 90% after deductible | 70% after deductible |
| Prosthetics, Durable Medical Equipment | 90% after deductible | 70% after deductible |
| Out-of-Network Care | | 70% of reasonable and customary charges after the deductible |
| National Coverage | Available in-network through UnitedHealthcare Options PPO network | |
| Annual Out-of-Pocket Maximum |
| In-Network and Out-of-Network Total Annual | $3,500 per person
$7,000 per family
Note: Out-of-pocket maximum includes the deductible |
| Lifetime Maximum | $5 million per person |
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