UnitedHealthcare

UHC Bronze Value HSA

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Plan Overview

Medical Deductible	Individual: $6,300 Family: $12,600 Per Person: $6,300
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: In network: You pay up to the deductible / $50 copay after you meet your deductible Out of network: Benefit not covered
Specialist	Standard: In network: You pay up to the deductible / $100 copay after you meet your deductible Out of network: Benefit not covered

Prescription Drug Information

Preferred Brand Drugs	Standard: In network: You pay up to the deductible / 35% of the cost of care after you meet your deductible Out of network: Benefit not covered
Non Preferred Brand Drugs	Standard: In network: You pay up to the deductible / 45% of the cost of care after you meet your deductible Out of network: Benefit not covered
Generic Drugs	Standard: In network: You pay up to the deductible / $30 copay after you meet your deductible Out of network: Benefit not covered
Specialty Drugs	Standard: In network: You pay up to the deductible / 50% of the cost of care after you meet your deductible Out of network: Benefit not covered

Inpatient Coverage

Hospital Services	Standard: In network: You pay up to the deductible / 30% of the cost of care after you meet your deductible Out of network: Benefit not covered
Inpatient Services	Standard: In network: You pay up to the deductible / 30% of the cost of care after you meet your deductible Out of network: Benefit not covered

Emergency and Urgent Care

Emergency Room

Standard: In network: You pay up to the deductible / 30% of the cost of care after you meet your deductible Out of network: You pay up to the deductible / 30% of the cost of care after you meet your deductible

Medical plan coverage offered by: UnitedHealthcare of Arizona, Inc.; Rocky Mountain Health Maintenance Organization, Incorporated in CO; UnitedHealthcare of Florida, Inc.; UnitedHealthcare of Georgia, Inc.; UnitedHealthcare of Illinois, Inc.; UnitedHealthcare Insurance Company in LA, TN and AL; Optimum Choice, Inc. in VA and MD; UnitedHealthcare Community Plan, Inc. in MI; UnitedHealthcare of North Carolina, Inc.; UnitedHealthcare of Oklahoma, Inc.; UnitedHealthcare of Texas, Inc.; and UnitedHealthcare of Oregon, Inc. in WA. Administrative Services provided by United HealthCare Services, Inc. or their affiliates.

Plan specifics and benefits may vary by coverage area and by plan category. Please review the plan details to learn more. This policy has exclusions, limitations, reduction of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable). By responding to this offer, you agree that a representative may contact you.

You are required to select a Primary Care Physician (PCP) within our network. Your PCP refers you to specialists when necessary. If you use a specialist without a referral or see a provider who is not in your network, you may have to pay the full cost of the benefits and services. Emergency services received by an out-of-network provider are covered.

Health Maintenance Organization, Inc. in Colorado and UnitedHealthcare Insurance Co. in Tennessee. Administrative Services provided by United HealthCare Services, Inc. or their affiliates.

UHC Bronze Value HSA

Plan Overview

Office Visit

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

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