Covered medical expenses

Important to remember…

UnitedHealthcare does not have the ability to make enrollment changes, such as to add a newborn. All enrollment modifications must be directed to your Benefits representative.

The UnitedHealthcare plan has no pre-existing condition limitation.

The following chart shows plan benefits for each covered health service. Benefits are available only when all of the following conditions are met:

Covered health services are provided while coverage is in effect.

Covered health services are provided before the date your coverage under the Plan is terminated.

The person who receives covered health services meets all the Plan's eligibility requirements.

Benefits for covered medical expenses - UHC PPO Plans and Out-of-Area Plan

The following table highlights the amount you pay for covered services (your share of the cost):

Amounts which you are required to pay as shown below in the chart below are based on eligible expenses or, for specific covered health services as described in the definition of "Recognized Amount" in "Medical plan definitions."


	UHC Choice PPO Plan		UHC Value PPO Plan		UHC Out-of-Area Plan
	In-Network	Out-of-Network (MNRP guidelines apply)	In-Network	Out-of-Network (MNRP guidelines apply)	Out-of-Area Plan (R&C guidelines apply)
Hospital charges: inpatient and outpatient services* after deductible unless noted
Room and board charges up to the semi-private room rate	20%	40%	20%	40%	20%
Intensive care unit	20%	40%	20%	40%	20%
Services and supplies, including diagnostic testing, laboratory services and X-rays	20%	40%	20%	40%	20%
Surgery	20%	40%	20%	40%	20%
Emergency treatment
Emergency room	$150 copayment	$150 copayment	$150 copayment	$150 copayment	$150 copayment
Urgent care/walk-in facility	$40 copayment	40%	$40 copayment	40%	20%
Preventive care services (Coverage for preventive care office visits may vary from what is shown in this table. See the chart under "Your medical benefits" for more information about your share of the cost for preventive care office visits.)
Routine physical exam	$0; not subject to deductible	40%; not subject to deductible	$0; not subject to deductible	40%; not subject to deductible	$0; not subject to deductible
Other preventive services, including children's immunizations, mammograms, PAP smears, X-rays and lab tests based on the recommendations of the U.S. Preventive Services Task Force (USPSTF) and Patient Protection Affordable Care Act (PPACA). Preventive testing services are limited to once per calendar year.	$0; not subject to deductible	40%; not subject to deductible	$0; not subject to deductible	40%; not subject to deductible	$0; not subject to deductible
Doctors and healthcare professionals-after deductible unless noted (Primary care physicians, including general practitioners, internists and pediatricians. Gynecologists are also considered primary care physicians for preventive annual exams only.)
Office visit - primary care physician	$25 copayment	40%	$25 copayment (no copayment after first visit for prenatal care)	40%	20%
Office visit - specialist	$40 copayment	40%	$40 copayment (no copayment after first visit for prenatal care)	40%	20%
Physician lab and X-ray services Prior authorization is required for out-of-network before Genetic Testing and sleep studies is performed. Otherwise, benefits will be subject to a $400 penalty.	20%	40%	20%	40%	20%
Medical care	20%	40%	20%	40%	20%
Surgery* (including Congenital Heart Disease surgery)	20%	40%	20%	40%	20%
Acupuncture services Limited to 30 visits per calendar year.	$40 copayment	40%	$40 copayment	40%	20%
Allergy testing and treatment	20%	40%	20%	40%	20%
Physical therapy Provided in all settings	20%	40%	20%	40%	20%
Occupational therapy	20%	40%	20%	40%	20%
Speech therapy	20%	40%	20%	40%	20%
Chiropractic treatment Medical necessity documentation required after 30 visits per calendar year. If visits exceed 30 in any calendar year, UnitedHealthcare must review and approve additional benefits for chiropractic treatment.	$40 copayment	40%	$40 copayment	40%	20%
Private duty nursing by an RN or LPN	20%	40%	20%	40%	20%
Podiatric treatment Covered only if for systematic disease or diabetes.	$40 copayment	40%	$40 copayment	40%	20%
Other services-after deductible unless noted
Ground Ambulance* Eligible expenses for emergency and non-emergency ground ambulance transport provided by an out-of-network provider will be determined as described under "Eligible expenses"	20%	20%	20%	20%	20%
Air Ambulance* Eligible expenses for emergency and non-emergency air ambulance transport provided by an out-of-network provider will be determined as described under "Eligible expenses"	20%	20%	20%	20%	20%
Anesthetics and their administration	20%	40%	20%	40%	20%
Cellular and Gene Therapy Services must be received at a Designated Provider.	Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this section.	Out-of-Network Benefits are not available	Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this section.	Out-of-Network Benefits are not available	Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this section.
Durable medical equipment (DME)*	20%	40%	20%	40%	20%
Gender Dysphoria Treatment*	20%	40%	20%	40%	20%
Fertility treatment Coverage for medical treatments up to a $25,000 lifetime maximum and prescription medication up to a $15,000 lifetime maximum. Participants must work with a nurse consultant through the Fertility Solutions (FS) program to identify the best treatment options and facilitate care through one of UHC's Centers of Excellence network clinics.	20%, up to lifetime maximums	Not covered	20%, up to lifetime maximums	Not covered	20%, up to lifetime maximums
Prosthetic and orthotic devices*	20%	40%	20%	40%	20%
Injectable drugs not intended for self administration	20%	40%	20%	40%	20%
Mental health and substance-related and addictive disorder treatment-after deductible unless noted
Inpatient*	20%	40%	20%	40%	20%
Residential day care*	20%	40%	20%	40%	20%
Outpatient* (outpatient professional services will be subject to the deductible and coinsurance; office visits are covered with no deductible)	$25 copayment	40%	$25 copayment	40%	20%
Special facilities
Birthing centers	20%	40%	20%	40%	20%
Home healthcare*	20%	40%	20%	40%	20%
Hospice care-inpatient and outpatient*	20%	40%	20%	40%	20%
Skilled nursing facility*	20%	40%	20%	40%	20%
Reminder: The Employee Assistance Program (EAP) provides free and confidential access to behavioral health professionals 24 hours a day, seven days a week. The EAP also provides up to three face-to-face counseling sessions per issue or problem at no cost to you. Contact the EAP at (833) 511-0159.

* Your network provider must obtain prior authorization from UnitedHealthcare, as described in this SPD before you receive certain covered health services. There are some network benefits, however, for which you are responsible for obtaining prior authorization from UnitedHealthcare.

Plan benefits for covered medical expenses - UHC Premium and Basic HSA Plans

The following table highlights the amount you pay for covered services (your share of the cost):

Amounts which you are required to pay as shown below in the chart below are based on eligible expenses or, for specific Covered Health Services as described in the definition of "Recognized Amount" in "Medical plan definitions."


	UHC Premium HSA Plan		UHC Basic HSA Plan
	In-Network	Out-of-Network (MNRP guidelines apply)	In-Network	Out-of-Network (MNRP guidelines apply)
Hospital charges: inpatient and outpatient services*-after deductible
Room and board charges up to the semi-private room rate	20%	40%	30%	50%
Intensive care unit	20%	40%	30%	50%
Services and supplies, including diagnostic testing, laboratory services and X-rays*	20%	40%	30%	50%
Surgery	20%	40%	30%	50%
Emergency treatment-after deductible
Emergency room	20%	20%	30%	30%
Urgent care/walk-in facility	20%	40%	30%	50%
Preventive care services (Coverage for preventive care office visits may vary from what is shown in this table. See the chart under "Your medical benefits" for more information about your share of the cost for preventive care office visits.)
Routine physical exam	$0; not subject to deductible	40%;after deductible	$0; not subject to deductible	50%; after deductible
Other preventive services Includes children's immunizations, mammograms, PAP smears, X-rays and lab tests based on the recommendations of the U.S. Preventive Services Task Force (USPSTF) and Patient Protection Affordable Care Act (PPACA). Preventive testing services are limited to once per calendar year.	$0; not subject to deductible	40%; not subject to deductible	$0; not subject to deductible	50%; not subject to deductible
Doctors and healthcare professionals-after deductible (Primary care physicians, including general practitioners, internists and pediatricians. Gynecologists are also considered primary care physicians for preventive annual exams only.)
Office visit - primary care physician	20%	40%	30%	50%
Office visit - specialist	20%	40%	30%	50%
Physician Lab and X-ray services Prior authorization is required before out-of-network Genetic Testing and sleep studies is performed. Otherwise, benefits will be subject to a $400 penalty.	20%	40%	30%	50%
Medical care	20%	40%	30%	50%
Surgery*	20%	40%	30%	50%
Acupuncture services Limited to 30 visits per calendar year.	20%	40%	30%	50%
Allergy testing and treatment	20%	40%	30%	50%
Physical and occupational therapy	20%	40%	30%	50%
Speech therapy	20%	40%	30%	50%
Chiropractic treatment Medical necessity documentation required after 30 visits per calendar year. If visits exceed 30 in any calendar year, UnitedHealthcare must review and approve additional benefits for chiropractic treatment.	20%	40%	30%	50%
Private duty nursing by an RN or LPN	20%	40%	30%	50%
Podiatric treatment Covered only if for systematic disease or diabetes.	20%	40%	30%	50%
Other services-after deductible
Ambulance* Eligible expenses for emergency and non-emergency ground and air ambulance transport provided by an out-of-network provider will be determined as described in "Eligible expenses."	20%	20%	30%	30%
Anesthetics and their administration	20%	40%	30%	50%
Durable medical equipment (DME)*	20%	40%	30%	50%
Gender Dysphoria Treatment*	20%	40%	30%	50%
Fertility treatment Coverage for medical treatments up to a $25,000 lifetime maximum and prescription medication up to a $15,000 lifetime maximum. Participants must work with a nurse consultant through the Fertility Solutions (FS) program to identify the best treatment options and facilitate care through one of UHC's Centers of Excellence network clinics.	20%, up to lifetime maximums	Not covered	30%, up to lifetime maximums	Not covered
Prosthetic and orthotic devices*	20%	40%	30%	50%
Injectable drugs not intended for self administration	20%	40%	30%	50%
Mental health and substance-related and addictive disorder services-after deductible
Inpatient*	20%	40%	30%	50%
Residential day care*	20%	40%	30%	50%
Outpatient*	20%	40%	30%	50%
Special facilities-after deductible
Birthing centers	20%	40%	30%	50%
Home healthcare*	20%	40%	30%	50%
Hospice care-inpatient and outpatient*	20%	40%	30%	50%
Skilled nursing facility*	20%	40%	30%	50%