Plan Details
Plan Name EPO - PVK
Description All Employees
Carrier United Healthcare Insurance Company
Effective Dates January 1, 2020 to January 1, 2021
Schedule of Benefits
General Plan Information
Annual Deductible/Individual $0
Annual Deductible/Family $0
Coinsurance 100%
Office Visit/Exam $20 copay
Outpatient Specialist Visit $20 copay
Annual Out-of-Pocket Limit/Individual $2,500
Annual Out-of-Pocket Limit/Family $5,000
Preventive Services
Well-Child Care 100%
Well Woman Exams 100%
Adult Periodic Exams with Preventive Tests 100%
Inpatient Hospital Services
Inpatient Hospitalization $250 copay
Semi-Private Room & Board; Including Services and Supplies $250 copay
Surgical Services
Outpatient Facility Charge 100%
Emergency Services
Emergency Room $100 copay waived if admitted
Urgent Care
Urgent Care Facility $50 copay
Mental Health Benefits
Inpatient Care $250 copay
Outpatient Care $20 copay per visit; Partial hospitalization/intensive outpatient treatment: 100%
Prescription Drug Benefits
Prescription Drug Deductible N/A
Generic $15 copay
Brand (Formulary/Preferred) $35 copay
Brand (Non-Formulary/Non-preferred) $50 copay
Number of Days Supply 31 days
Mail Order
Generic $37.50 copay
Brand (Formulary/Preferred) $87.50 copay
Brand (Non-Formulary/Non-preferred) $125 copay
Number of Days Supply for Mail Order 90 days
Other Services and Supplies
Durable Medical Equipment & Prosthetic Devices 100% Covers 1 per type of DME (including repair/replacement) every 3 years
Chiropractic Services $20 copay; Limited to 24 visits per year
Acupuncture $20 copay; Limited to 20 visits per year
Outpatient Rehabilitative Therapy Services
Physical $20 copay; Limited to 20 visits per year