Category of Service stringclasses 9
values | UHS Cost stringclasses 4
values | In-network Cost stringclasses 5
values | Out-of-network Cost stringclasses 4
values | Limitations/Important Notes stringclasses 7
values |
|---|---|---|---|---|
Primary Care Visit | No charge | 10% coinsurance | 40% coinsurance | null |
Specialist Visit | No charge | 10% coinsurance | 40% coinsurance | Chiropractic care subject to coinsurance |
Preventive Care/Screening/Immunization | No charge for Student/Spouse | No charge for children | 40% coinsurance | May have to pay for non-preventive services |
Emergency Room Care | Not covered | $100 copay/visit, 0% coinsurance for medical emergency | Same as In-network for medical emergency | Copayment waived if admitted |
Imaging (CT/PET scans, MRIs) | Not covered | 10% coinsurance | 40% coinsurance | Pre-certification required |
Outpatient Surgery - Facility Fee | Not covered | 10% coinsurance | 40% coinsurance | Pre-certification required |
Prescription Drugs - Tier 1 (Generic) | $10 copay/prescription | $10 copay/prescription | Not covered | Deductible does not apply; covers up to 31-day supply |
Home Health Care | Not covered | 10% coinsurance | 40% coinsurance | Limited to 60 visits/year; pre-certification required |
Children's Eye Exam | Not covered | $25 copay/exam, 20% coinsurance | $25 copay/exam, 20% coinsurance | Covers one exam/year |
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