Plan Details
Plan Name PPO - AB6G
Description All Employees
Carrier United Healthcare Insurance Company
Effective Dates January 1, 2020 to January 1, 2021
In-Network Benefits Out-of-Network Benefits
General Plan Information
Annual Deductible/Individual $200 $200
Annual Deductible/Family $400 $400
Coinsurance 90% 70%
Office Visit/Exam $20 copay 70% after deductible
Outpatient Specialist Visit $20 copay 70% after deductible
Annual Out-of-Pocket Limit/Individual $2,200 $5,200
Annual Out-of-Pocket Limit/Family $4,400 $10,400
Preventive Services
Well-Child Care 100% Not covered
Well Woman Exams 100% Not covered
Adult Periodic Exams with Preventive Tests 100% Not covered
Inpatient Hospital Services
Inpatient Hospitalization 90% after deductible 70% after deductible
Semi-Private Room & Board; Including Services and Supplies 90% after deductible 70% after deductible
Surgical Services
Outpatient Facility Charge 90% after deductible 70% after deductible
Emergency Services
Emergency Room 90%, $100 Emergency room per occurrence deductible applies prior to the overall deductible 90%; $100 Emergency room per occurrence deductible applies prior to the overall deductible
Urgent Care
Urgent Care Facility $20 copay 70% after deductible
Mental Health Benefits
Inpatient Care 90% after deductible 70% after deductible
Outpatient Care $20 copay; Partial hospitalization/intensive outpatient treatment: 90% after deductible 70% after deductible
Prescription Drug Benefits
Prescription Drug Deductible N/A N/A
Generic $15 copay $15 copay
Brand (Formulary/Preferred) $35 copay $35 copay
Brand (Non-Formulary/Non-preferred) $50 copay $50 copay
Number of Days Supply 31 days 31 days
Mail Order
Generic $37.50 copay Not covered
Brand (Formulary/Preferred) $87.50 copay Not covered
Brand (Non-Formulary/Non-preferred) $125 copay Not covered
Number of Days Supply for Mail Order 90 days N/A
Other Services and Supplies
Durable Medical Equipment & Prosthetic Devices 90%; Covers 1 per type of DME (including repair/replacement) every 3 years. 70%; Covers 1 per type of DME (including repair/replacement) every 3 years. Preauthorization required for DME over $1,000
Chiropractic Services $20 copay; Limited to 24 visits per year 70% after deductible; Limited to 24 visits per year
Acupuncture $20 copay; Limited to 20 visits per calendar year 70% after deductible; Limited to 20 visits per calendar year
Outpatient Rehabilitative Therapy Services
Physical $20 copay; Limited to 20 visits per year 70% after deductible; Limited to 20 visits per year