StdHighGoldUHCChoicePlusGold01CoverageforEmployeeFamilyPlanTypePOS TheSummaryofBenefitsandCoverageSBCdocumentwillhelpyouchooseahealthplan TheSBCshowsyouhowyouandtheplan wouldsharethecostforco ID: 958976
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StdHighGold:UHCChoicePlusGold0-1Page1of7SummaryofBenefitsandCoverage:WhatthisPlanCovers&WhatYouPayforCoveredServicesCoveragePeriod:01/01/2022-12/31/2022 StdHighGold:UHCChoicePlusGold0-1Coveragefor:Employee/Family|PlanType:POS TheSummaryofBenefitsandCoverage(SBC)documentwillhelpyouchooseahealthplan .TheSBCshowsyouhowyouandtheplan wouldsharethecostforcoveredhealthcareservices.NOTE:Informationaboutthecostofthisplan (calledthepremium )wil
lbeprovidedseparately.Thisisonlyasummary.Formoreinformationaboutyourcoverage,ortogetacopyofthecompletetermsofcoverage,visituhc.com/shopmaorbycalling1-877-856-2430.Forgeneraldefinitionsofcommonterms,suchasallowed amount billing ,coinsurance ,copayment ,deductible ,provider ,orotherunderlined terms,seetheGlossary.YoucanviewtheGlossaryatwww.healthcare.gov/sbc-glossaryorcall1-866-487-2365torequestacopy. ImportantQuestionsAnswersWhyThisMat
ters: Whatistheoveralldeductible ?Network :$0out-of-Network :$3,000Individual/$6,000FamilyPercalendaryear.Generally,youmust uptothedeductible amountbeforethisplan beginstopay. Arethereservicescoveredbeforeyoumeetyourdeductible ?YesThisplancoversitemsandservicesevenifyouhaven'tyetmetthedeductible amount. Arethereotherdeductibles forspecificservices?No.Youdon'thavetomeetdeductibles forspecificservices. Whatis limit forthisplan ?Network
:$5,000Individual/$10,000Familyout-of-Network :$15,000Individual/$30,000FamilyTheout-of-pocket limit isthemostyoucouldpayinayearforcoveredservices.Ifyouhaveotherfamilymembersinthisplan ,theyhavetomeettheirownout-of-pocket limits untiltheoverallfamilyout-of-pocket limit hasbeenmet. Whatisnotincludedintheout-of-pocket limit ? ,balance-billing charges(unlessbalancedbillingisprohibited),healthcarethisplan doesn'tcoverandpenaltiesforfailur
etoobtainpreauthorization forservices.Eventhoughyoupaytheseexpenses,theydon'tcounttowardtheout-of-pocket limit . Willyoupaylessifyouuseanetwork provider ?Yes.Seeuhc.com/shopmadocfindchoiceplusorcall1-877-856-2430foralistofnetwork providers .Thisplan usesaprovider Network . intheplan's Network .Youwillpaythemostifyouuseanout-of-Networkprovider ,andyoumightreceiveabillfromaprovider forthedifferencebetweentheprovider's chargeandwhatyourp
lan pays(balancebilling) .Beaware,yourNetworkprovider mightuseanout-of-Networkprovider forsomeservices(suchaslabwork).Checkwithyourprovider beforeyougetservices. toseeaspecialist ?No.Youcanseethespecialist youchoosewithoutareferral . Page3of7 MedicalEventServicesYouMayNeedWhatYouWillPay Provider(YouwillpaytheProvider(YouwillpaytheLimitations,Exceptions,&OtherImportant Ifyouneeddrugstotreatyourillnessor Moreinformationaboutprescription
drugcoverageisavailableatwww.uhc.com/shopmad-ruglist202 Tier1-YourLowest-Cost notapply.Retail:$25copay Mail-Order:$50 Deductible notapply.Retail:$25copay Provider meanspharmacyforpurposesofthissection.Retail:Uptoa31daysupply.Mail-Order*:Uptoa90daysupplyor*Preferred90DayRetailNetwork pharmacy.Ifyouuseanout-of-Network pharmacy(includingamailorderpharmacy),youmayberesponsibleforanyamountoverthe amount .Copay isperprescriptionorderuptothe
daysupplylimitlistedYoumayneedtoobtaincertaindrugs,includingcertainspecialty drugs ,fromapharmacydesignatedbyus.Certaindrugsmayhaveapreauthorization requirementormayresultinahighercost.Youmayberequiredtousealower-costdrug(s)priortobenefitsunderyourpolicybeingavailableforcertainprescribeddrugs.Seethewebsitelistedforinformationondrugscoveredbyyour .Notalldrugsarecovered.PrescriptionDrugList(PDL):Advantage.Network:National.Ifadispenseddr
ughasachemicallyequivalentdrug,thecostdifferencebetweendrugsinadditiontoanyapplicablecopay and/orcoinsurance maybeapplied.CertainpreventivemedicationsandTier1contraceptivesarecoveredatNoCharge. Tier2-YourMidrange-Cost notapply.Retail:$50copay Mail-Order:$100 Deductible notapply.Retail:$50copay Tier3-YourMidrange-Cost notapply.Retail:$75copay Mail-Order:$225 Deductible notapply.Retail:$75copay Tier4-AdditionalHigh-CostOptionsNotApplica
bleNotApplicable IfyouhaveoutpatientsurgeryFacilityfee(e.g.,ambulatorysurgerycenter)$500copay visit,deductible doesnotapply20%coinsurance Preauthorization requiredforcertainservicesfor orbenefitreducesto50%ofallowed. Physician/surgeonfeesNoCharge20%coinsurance None IfyouneedmedicalattentionEmergencyroomcare $300copay visit,deductible doesnotapply.$300copay visit,deductible doesnotapply. Emergencymedical transportation NoChargeNoCharge