Enhanced PPO Plan

Enhanced PPO Plan

With this option, you have the flexibility to see providers who meet yours or your family’s health care needs. “PPO” refers to “preferred provider organization” – an important feature of this type of medical plan.

Here’s how it works:

The Enhanced PPO option has two level of benefits: Network and Non-network. Each time you need care you decide whether to see a network or non-network provider. You receive higher benefits when you see network providers. Network providers will also file claims for you. To see a list of network providers for your area, sign on to www.myuhc.com.

Deductible applies to all network and non-network services except where noted.
Summary of Benefits	Network Provider	Non-Network Provider
Physician Services Primary Care Physicians Specialists	$25 Co-payment $35 Co-payment (Deductible does not apply)	60% of MNRP*
Preventive Care	100% (Deductible does not apply)	Not-covered
Well Baby Care	100% (Deductible does not apply)	Not-covered
Hospital Inpatient	100%	60% of MNRP*
Hospital Outpatient	100%	60% of MNRP*
Emergency Room	100% after $90 co-pay for emergencies (deductible does not apply) (co-payment is not waived even if admitted) 80% after $140 co-pay for non-emergencies (deductible applies) (co-payment is not waived even if admitted)	100% of MNRP* after $90 co-pay for emergencies (deductible does not apply) (co-payment is not waived even if admitted) 60% of MNRP* after $140 co-pay for non-emergencies (deductible applies) (co-payment is not waived even if admitted)
Urgent Care Centers	$35 Co-payment (Deductible does not apply)	60% MNRP*
Surgery	100%	60% MNRP*
X-ray & laboratory	100%	60% MNRP*
Prescription Drugs (one month supply)	Tier 1: 90% ($15 min/$25/max) Tier 2: 80% ($30 min/$55 max) Tier 3: 60% ($60 min/ $85 max) (Deductible does not apply)	Not covered
Mail Order Prescription (3 month Supply)	Tier 1: 90% ($25 min/$45/max) Tier 2: 80% ($60 min/$110max) Tier 3: 60% ($120min/$170 max) (Deductible does not apply)	Not covered
Mental Health & Chemical Dependency	Inpatient 100% Outpatient $25 co-payment	Inpatient 50% Outpatient 50%
Deductible **	$450/person $900/family	$600/person $1,200/family
Co-insurance maximum	$1,800/person $3,600/ family	$6,200/person $12,400/ family
Life time maximum	none

* Maximum Non-Network Reimbursement Program (MNRP) as determined by United HealthCare

** Deductible applies to all network and non-network services except where noted.

Employee Bi-Weekly Cost (Effective January 1, 2017)

Employee Only	$100.97/bi-weekly
Employee & Child(ren)	$192.97/bi-weekly
Employee & Spouse	$233.47/bi-weekly
Employee, Spouse & Child(ren)	$346.07/bi-weekly

Primary Care Physicians includes Family Practice, General Practice, Internal Medicine, Pediatricians, and OBGYNs.

Revised: March 17, 2017.