If you have a test (x-ray, blood work) 20% Coinsurance 40% Coinsurance Prior Authorization required for Sleep Studies. Imaging (CT/PET scans, MRIs) 20% Coinsurance 40% Coinsurance Advance Notification required If you need drugs to treat your illness or condition More information about is available at www.myuhc.com Tier 1 Retail & Mail Order for 1-30 day supply: $5 Copay Retail & Mail Order for 31-90 day supply: $10 Copay Retail: $5 Provider means pharmacy for purposes of this section. Retail: Up to a 30 and 90 day supply Mail-Order: Up to a 90 day supply You may need to obtain certain including certain specialty drugs, from a pharmacy designated by us. Certain drugs may have a pre-authorization requirement or may result in a higher cost. If you use a non-network pharmacy (including a mail order pharmacy), you are responsible for any amount over the allowed amount. You may be required to use a lower-cost drug(s) prior to benefits under your policy being available for certain prescribed drugs. Tier 1 contraceptives covered at No Charge. See the website listed for information on drugs covered by your plan. Not all drugs are covered. Prescription Out of Pocket limit: $2,250 Individual / $4,500 Family. Prescription drugs to the prescription drug out-of pocket-limit. Tier 2 Retail & Mail Order for 1-30 day supply: $40 Copay Retail & Mail for day supply: $80 Copay Retail: $40 Copay Tier 3 Retail & Mail for day supply: $60 Copay Retail & Mail Order for 31-90 day supply: $120 Copay Retail: $60 Copay Tier 4 Retail: N/A Mail Order: N/A Retail: N/A If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% Coinsurance 40% Coinsurance None Physician/surgeon fees 20% Coinsurance 40% Coinsurance None 30
other special health needs 20% Coinsurance 40% Coinsurance 30 visits Spinal Manipulation; 20 visits each Physical Therapy, Occupational Therapy, Cognitive Rehab Therapy, & Speech Therapy; 36 visits for Cardiac Rehab, 20 visits for Pulmonary Rehab. Visits are combined In & Out of Network per plan year. Not Covered Not Covered None 20% Coinsurance 40% Coinsurance Prior Authorization required 60 day limit per plan year combined Network & Non-Network. 20% Coinsurance 40% Coinsurance Prior Authorization required for DME devices that cost more than $1,000 per device (Purchase or cumulative rental). 20% Coinsurance 40% Coinsurance Prior Authorization required Inpatient non-network. If your child needs dental or eye care Children’s eye exam Not Covered Not Covered None Children’s glasses Not Covered Not Covered None Children’s dental Not Covered Not Covered None Excluded Services & Covered Services: Services Your Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other .) Acupuncture Adult routine vision exam (i.e. refraction) Child dental check-up routine vision exam (i.e. refraction) Child vision glasses Cosmetic Surgery Dental Care Habilitation services Infertility treatment Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Weight loss programs Acupuncture Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your document.) Bariatric Surgery Hearing aids Routine foot care