2019 SHBP Benefts at a Glance
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1 UnitedHealthcare SHBP Members State of Georgia 2019 SHBP Benefts at a Glance For more coverage details for each of these plans, please visit welcometouhc.com/shbp or call Medical Choice HMO Network credits cost to: Network credits cost to:** Out-of- Network credits cost to:** Deductible You $1,300 $580 $3,500 $2,780 $7,000 $6,280 You + Child(ren) $1,950 $1,230 $7,000 $6,280 $14,000 $13,280 You + Spouse $1,950 $510 $7,000 $5,560 $14,000 $12,560 You + Family $2,600 $1,160 $7,000 $5,560 $14,000 $12,560 Out-of-pocket limit You $4,000 $3,280 $6,450 $5,730 $12,900 $12,180 You + Child(ren) $6,500 $5,780 $12,900 $12,180 $25,800 $25,080 You + Spouse $6,500 $5,060 $12,900 $11,460 $25,800 $24,360 You + Family $9,000 $7,560 $12,900 $11,460 $25,800 $24,360 3 incentive credit maximums (includes UnitedHealthcare s 480 credit bonus) Your earned incentive credits your out-of-pocket costs by: You You + Child(ren) You + Spouse - 1,440 Family - 1,440
2 Choice HMO Co-insurance (Plan Pays) 80% 70% 50% Covered services Preventive Care Services When provided by network providers and properly coded as preventive care within the 100% 100% Not covered meaning of the Afordable Care Act (ACA) Eye Exam Routine (limited to one exam every 24 months; no out-of-network 100% 100% Not covered coverage) Routine Maternity Care Physician Services (prenatal, delivery and postpartum) 100% Non-Routine Maternity Care Physician Services (prenatal, delivery and postpartum) Primary care physician (PCP), Specialist or Clinic ofce visits (treatment of illness or injury) Urgent Care Visit Emergency Room (treatment of an emergency medical condition or injury) Virtual Visits $35 PCP co-pay $45 Specialist co-pay $35 PCP co-pay $45 Specialist co-pay $35 co-pay $150 co-pay (waived if admitted) $35 PCP co-pay 70%* Not covered
3 Choice HMO Medical Network Network Out-of-Network Ambulance (emergency only) 100% Outpatient Surgery 80%* Hospital Services (inpatient/ outpatient facility/ 80%* outpatient professional) Hospital Services (inpatient professional) 100%* Outpatient Rehabilitation Physical, Speech, Occupational, Cardiac, Pulmonary Therapy (40 $25 co-pay visits per therapy per plan year) Chiropractic Visit - spinal manipulation only (20 visits per plan year) Hearing - Exam and Fitting (ofce visit) Hearing Aid Allowance Children (up to age 19) - $3,000 per hearing impaired ear every 4 years Adult - $1,500 max/5 years $45 co-pay Hearing Aid exam: $35 Primary Physician $45 Specialist co-pay per visit then 100% of eligible expenses Hearing Aid: 100% Hearing Aid: 100%* Hearing Aid: 100%*
4 Behavioral Health Mental Health and Substance Use Disorder Inpatient & Outpatient Facility, and Residential Treatment Centers. NOTE: Prior approval required. Mental Health/Substance Use (inpatient professional) Mental Health/Substance Use Disorder Outpatient Visits- Professional & Methadone Clinics Choice HMO 80%* 100%* $35 PCP co-pay $10 co-pay for group/ family therapy Pharmacy - Administered by CVS Caremark Retail Pharmacy (Up to a 31-day supply) 90-Day Mail Order Tier 1 $20 Tier 2 $50 Tier 3 $90 Tier 1 $50 Tier 2 $125 Tier 3 $225 This information is a general description of your coverage. It is not a contract and does not replace the ofcial beneft coverage documents which may include a Summary Plan Description. If descriptions, percentages, and dollar amounts in this guide difer from what is in the ofcial beneft coverage documents, the ofcial benefts coverage documents prevail. available please refer to the ofcial plan documents. The UnitedHealthcare plan with Health Savings Account (HSA) is a high deductible health plan (HDHP) that is designed to comply with IRS requirements so eligible enrollees may open a Health Savings Account (HSA) with a bank of their choice or through Optum Bank, Member of FDIC. The HSA refers only and specifcally to the Health Savings Account that is provided in conjunction with a particular bank, such as Optum Bank, and not to the associated HDHP.
5 The company does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities. We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card TTY 711, Monday through Friday, 8 a.m. to 8 p.m. ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identifcación. 請注意 : 如果您說中文 (Chinese), 我們免費為您提供語言協助服務 請撥打會員卡所列的免付費會員電話號碼 SHBP Open Enrollment Administrative services provided by United HealthCare Services, Inc. or their afliates. Facebook.com/UnitedHealthcare Twitter.com/UHC Instagram.com/UnitedHealthcare YouTube.com/UnitedHealthcare MT / United HealthCare Services, Inc
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SECOND QUARTER 2019 SMALL GROUP PRODUCT PORTFOLIO
SECOND QUARTER 2019 SMALL GROUP PRODUCT PORTFOLIO A Benefi ts of BlueShield Innovative plan designs Expanded (EX) network plans Enhanced network access with POS plans locally and PPO plans for out-of-area
Choice Plus Health Savings Plan Discount Tire/America s Tire/Discount Tire Direct
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.myuhc.com or by calling 1-855-837-1612. Important Questions
Summary of Benefits and Coverage:
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018 Health Net of CA: Blue & Gold HMO Coverage for: All Covered Members Plan
Important Questions Answers Why this matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsvt.com/planj_cert or www.bcbsvt.com/planj_rider or