HSA $1,750
We offer the choice of three medical plans through UnitedHealthcare (UHC). All of the medical options include coverage for prescription drugs through OptumRx, administered by UHC.
Plan Details
- Carrier
- UNITEDHEALTHCARE
- Plan Type
- HDHP
- Network
- UHC Choice Plus
- Has Out Of Network Coverage
- Yes
- HSA Eligible
- Yes
- FSA Eligible
- -
- Employer Account Contribution
- $500 Employee Only / $1,000 all other tiers
Premiums (Bi-Weekly)
| Coverage Tier | You Pay | NOVA Pays |
|---|---|---|
| Employee | $49.28 | $316.62 |
| Employee + Spouse | $223.38 | $508.41 |
| Employee + Child(ren) | $207.18 | $488.02 |
| Family | $304.38 | $610.35 |
Employee
- You Pay
- $49.28
- NOVA Pays
- $316.62
Employee + Spouse
- You Pay
- $223.38
- NOVA Pays
- $508.41
Employee + Child(ren)
- You Pay
- $207.18
- NOVA Pays
- $488.02
Family
- You Pay
- $304.38
- NOVA Pays
- $610.35
Medical Services
| In-network | Out-of-network | |
|---|---|---|
| Annual deductible (Individual/Family) | $1,750 / $3,500 | $6,000 / $12,000 |
| Embedded / Non-Embedded | Non-Embedded | Non-Embedded |
| Out-of-pocket maximum (Individual/Family)* | $3,500 / $7,000 | $20,000 / $40,000 |
| Preventive care | No Copay | 30% |
| Primary physician office visit | 20% | 40% |
| Specialist office visit | 20% | 40% |
| Virtual Care | No Copay | 30% |
| Inpatient hospital services | 20% | 40% |
| Outpatient hospital services (lab*, x-ray, diagnostic) | 40% | 40% |
| Advanced diagnostics* | You pay a $500 per occurrence deductible per service prior to and in addition to paying any Annual Deductible and any coinsurance amount. 40% | 40% |
| Urgent care | 20% | 40% |
| Emergency room care | 20% | 20% |
| Annual Health Savings Account (HSA) Employer Contributions | $500 Employee Only / $1,000 all other tiers | $500 Employee Only / $1,000 all other tiers |
Annual deductible (Individual/Family)
- In-network
- $1,750 / $3,500
- Out-of-network
- $6,000 / $12,000
Embedded / Non-Embedded
- In-network
- Non-Embedded
- Out-of-network
- Non-Embedded
Out-of-pocket maximum (Individual/Family)*
- In-network
- $3,500 / $7,000
- Out-of-network
- $20,000 / $40,000
Preventive care
- In-network
- No Copay
- Out-of-network
- 30%
Primary physician office visit
- In-network
- 20%
- Out-of-network
- 40%
Specialist office visit
- In-network
- 20%
- Out-of-network
- 40%
Virtual Care
- In-network
- No Copay
- Out-of-network
- 30%
Inpatient hospital services
- In-network
- 20%
- Out-of-network
- 40%
Outpatient hospital services (lab*, x-ray, diagnostic)
- In-network
- 40%
- Out-of-network
- 40%
Advanced diagnostics*
- In-network
- You pay a $500 per occurrence deductible per service prior to and in addition to paying any Annual Deductible and any coinsurance amount. 40%
- Out-of-network
- 40%
Urgent care
- In-network
- 20%
- Out-of-network
- 40%
Emergency room care
- In-network
- 20%
- Out-of-network
- 20%
Annual Health Savings Account (HSA) Employer Contributions
- In-network
- $500 Employee Only / $1,000 all other tiers
- Out-of-network
- $500 Employee Only / $1,000 all other tiers
- *Includes Deductible and Copayments | After deductible | *Using UHC’s Designated Network will result in greater savings on these services.
Retail (31-day supply)
| In-network | Out-of-network | |
|---|---|---|
| Tier 1 | No Copay | No Copay |
| Tier 2 | No Copay | No Copay |
| Tier 3 | No Copay | No Copay |
| Tier 4 | No Copay | No Copay |
Tier 1
- In-network
- No Copay
- Out-of-network
- No Copay
Tier 2
- In-network
- No Copay
- Out-of-network
- No Copay
Tier 3
- In-network
- No Copay
- Out-of-network
- No Copay
Tier 4
- In-network
- No Copay
- Out-of-network
- No Copay
- *Includes Deductible and Copayments | After deductible | *Using UHC’s Designated Network will result in greater savings on these services.
Mail order (90-day supply)
| In-network | Out-of-network | |
|---|---|---|
| Tier 1 | No Copay | Not Covered |
| Tier 2 | No Copay | Not Covered |
| Tier 3 | No Copay | Not Covered |
| Tier 4 | No Copay | Not Covered |
Tier 1
- In-network
- No Copay
- Out-of-network
- Not Covered
Tier 2
- In-network
- No Copay
- Out-of-network
- Not Covered
Tier 3
- In-network
- No Copay
- Out-of-network
- Not Covered
Tier 4
- In-network
- No Copay
- Out-of-network
- Not Covered
- *Includes Deductible and Copayments | After deductible | *Using UHC’s Designated Network will result in greater savings on these services.
Plan Notes
- NOVA will contribute $500 per year ($19.24 per paycheck) if you are enrolled in employee only coverage, or $1,000 a year if you are enrolled in any tier that covers dependents. Company HSA contributions will be deposited each payroll, not as a lump sum.
- After the deductible is met, prescription drugs have no copay.