Medical Plan Comparison Chart
| Medical | PPO 1500 / 3000 | PPO HSA 2250 / 4500 | EPO HSA 4000 / 8000 | Surest Zero-Deductible plan |
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|---|---|---|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of- Network |
|
| Plan Features | ||||||||
| Deductible | ||||||||
| Individual / Family | $1,500 / $3,000 | $3,000 / $6,000 | $2,250 / $4,500 | $6,500 / $13,000 | $4,000 / $8,000 | Not Covered | No deductible | |
| HSA: Employer Contribution | Not applicable | $500 single / $1,000 family | $0 | Not applicable | ||||
| Net Deductible | ||||||||
| Individual / Family | $1,500 / $3,000 | $3,000 / $6,000 | $1,750 / $3,500 | $6,000 / $12,000 | $4,000 / $8,000 | Not Covered | No deductible | |
| Out-of-Pocket Maximum | ||||||||
| Individual / Family | $5,000 / $10,000 | $9,000 / $18,000 | $5,000 / $10,000 | $13,000 / $26,000 | $6,500 / $13,000 | Not Covered | $6,000 / $12,000 | $12,000 / $24,000 |
| Copay Amounts = Amounts You Pay % = the Plan Pays |
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| Preventive Care | ||||||||
| Preventive Services | 100% covered | 50% after deductible | 100% covered | 50% after deductible | 100% covered | Not Covered | 100% covered | $150 copay |
| Physician Services | ||||||||
| Office Visits | $15 copay | 50% after deductible | 80% after deductible | 50% after deductible | 70% after deductible | Not Covered | $25–$130 copay | $220 copay |
| Specialist Visit | $15 / $30 copay | 50% after deductible | 80% after deductible | 50% after deductible | 70% after deductible | Not Covered | $25–$130 copay | $220 copay |
| Testing | ||||||||
| High-Tech Imaging | 75% after deductible | 50% after deductible | 80% after deductible | 50% after deductible | 70% after deductible | Not Covered | $125–$775 copay | $2,325 copay |
| Lab & X-ray | 75% after deductible | 50% after deductible | 80% after deductible | 50% after deductible | 70% after deductible | Not Covered | $30–$90 copay | Up to $2,700 copay |
| Emergency Medical Care | ||||||||
| Emergency Room | $250 copay | 80% after deductible. | 70% after deductible | $650 copay | ||||
| Urgent Care | $30 copay | 50% after deductible | 80% after deductible | 50% after deductible | 70% after deductible | $80 copay | $210 copay | |
| Hospital Care | ||||||||
| Outpatient Surgery | 75% after deductible | 50% after deductible | 80% after deductible | 50% after deductible | 70% after deductible | Not Covered | $40–$3,000 copay | Up to $9,000 copay |
| Inpatient Hospital | 75% after deductible | 50% after deductible | 80% after deductible | 50% after deductible | 70% after deductible | Not Covered | $200–$3,000 copay | Up to $9,000 copay |
| Virtual Visits | $0 | $0 | 80% after deductible | 50% after deductible | 70% after deductible | Not covered | Varies | Not covered |
UHC Hearing Aid Coverage Chart
| Medical | PPO 1500 / 3000 | PPO HSA 2250 / 4500 | EPO HSA 4000 / 8000 | |||
|---|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | |
| Copay Amounts = Amounts You Pay % = the Plan Pays |
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| Hearing Aids | 75% after deductible | 75% after deductible | 80% after deductible | 80% after deductible | 70% after deductible | Not Covered |