2009 Medica Choice National
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|
| |
In-Network |
Out-of-Network |
| Deductibles |
None |
$500 |
| Emergency Care |
$50 – Waived if admitted |
80% of first $2,000, then 100% |
| Urgent Care |
$25 office visit copay |
80% of first $2,000, then 100% |
| Network Hospital - General |
$200 admission copay |
70% after deductible |
| Network Hospital - Mental Health/Chemical Dependency |
$200 admission copay |
70% after deductible |
| In-Network Health Care Services |
| Preventive Care |
100% coverage |
70% after deductible |
| Physician |
$25 office visit copay |
70% after deductible |
| Eye and Hearing Exam (nonroutine) |
$25 office visit copay |
70% after deductible |
| Outpatient/surgery |
$75 outpatient copay |
70% after deductible |
| Outpatient Mental Health/Chemical Dependency |
$25 office visit copay |
70% after deductible |
| Chiropractic Care |
$25 office visit copay |
70% after deductible |
| Physical, Speech, Occupational Therapy |
$25 office visit copay |
70% after deductible |
| Home Health Care |
$25 home visit copay |
70% after deductible |
| Prosthetics, Durable Medical Equipment |
80% coverage, including hearing aids |
70% after deductible |
| Out-of-Network Care |
|
$500 deductible per person
$1,000 deductible per family
70% coinsurance of reasonable and customary charges up to annual out-of-pocket maximum |
| National Coverage |
Available in-network through UnitedHealthcare Options PPO network |
|
| Annual Out-of-Pocket Maximum |
| In-Network and Out-of-Network Total Annual |
$2,500 per person
$4,000 per family |
|
Lifetime Maximum |
$5 million per person |
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