Deductible 

Individual/Family (per calendar year)

$5,000/$10,000

$2,000/$4,000

$3,000/$6,000

$2,500/$5,000

Out-Of-Pocket max (includes deductible)
Individual/Family (per calendar year)

$6,000/$12,000

$6,500/$13,000

$6,350/$12,700

$4,000/$8,000

Co-insurance

80% paid by UHC
20% paid by You

80% paid by UHC
20% paid by You

80% paid by UHC
20% paid by You

100% paid by UHC
0% paid by You

Preventative Care

100% covered 

100% covered

100% covered

100% covered 

Office Visit
Primary Care Phy
Specialist
Telehealth

Ded/Coinsurance
Ded/Coinsurance
Ded/Coinsurance

$5 Copay
$100 Copay
$5 Copa

$30 Copay
$60 Copay
$30 Copay

$25 Copay
$50 Copay
$25 Copay

Retail Pharmacy Drug Coverage
Tier 1/Tier2/Tier3/Tier4

$10/$35/$60/NA
After Deductible

$5/$50/$100/$250
Rx Ded for All Tiers

$15/$40/$75

$15/$40/$75

Mail order Pharmacy Drug Coverage 1/Tier2/Tier3/Tier4

$25/$88/$150/NA
After Deductible

13/$125/$250/NA
Rx Ded for All Tiers

$38/$100/$188

$38/$100/$ 188

Urgent Care

Ded/Coinsurance

$50 Copay

$100 Copay

$100 Copay

Inpatient Hospital Care

Ded/Coinsurance

Ded/Coinsurance

Ded/Coinsurance

Deductible

Outpatient Hospital Care

Ded/Coinsurance

Ded/Coinsurance

Ded/Coinsurance

Deductible

Hi-Tech Diagnostics

Ded/Coinsurance

Ded/Coinsurance

Ded/Coinsurance

Deductible

Emergency Services

Ded/Coinsurance

$250 Copay + Coinsurance

$300 Copay

$300 Copay

Lifetime Maximum

Unlimited

Unlimited

Unlimited

Unlimited