HSA $5,000
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 | $19.23 | $253.98 |
| Employee + Spouse | $163.48 | $382.94 |
| Employee + Child(ren) | $151.49 | $367.62 |
| Family | $223.43 | $459.61 |
Employee
- You Pay
- $19.23
- NOVA Pays
- $253.98
Employee + Spouse
- You Pay
- $163.48
- NOVA Pays
- $382.94
Employee + Child(ren)
- You Pay
- $151.49
- NOVA Pays
- $367.62
Family
- You Pay
- $223.43
- NOVA Pays
- $459.61
Medical Services
| In-network | Out-of-network | |
|---|---|---|
| Annual deductible (Individual/Family) | $5,000 / $10,000 | $10,000 / $20,000 |
| Embedded / Non-Embedded | Embedded | Embedded |
| Out-of-pocket maximum (Individual/Family)* | $8,300 / $16,600 | $16,600 / $33,200 |
| 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% | 20% |
| 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
- $5,000 / $10,000
- Out-of-network
- $10,000 / $20,000
Embedded / Non-Embedded
- In-network
- Embedded
- Out-of-network
- Embedded
Out-of-pocket maximum (Individual/Family)*
- In-network
- $8,300 / $16,600
- Out-of-network
- $16,600 / $33,200
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
- 20%
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 | $10 | $10 |
| Tier 2 | $35 | $35 |
| Tier 3 | $75 | $75 |
| Tier 4 | $150 | $150 |
Tier 1
- In-network
- $10
- Out-of-network
- $10
Tier 2
- In-network
- $35
- Out-of-network
- $35
Tier 3
- In-network
- $75
- Out-of-network
- $75
Tier 4
- In-network
- $150
- Out-of-network
- $150
- *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 | $25 | Not Covered |
| Tier 2 | $87.50 | Not Covered |
| Tier 3 | $187.50 | Not Covered |
| Tier 4 | $375 | Not Covered |
Tier 1
- In-network
- $25
- Out-of-network
- Not Covered
Tier 2
- In-network
- $87.50
- Out-of-network
- Not Covered
Tier 3
- In-network
- $187.50
- Out-of-network
- Not Covered
Tier 4
- In-network
- $375
- 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.
- Prescription copays apply after the deductible is met.
Footnotes
- This is a summary of coverage; please refer to your summary plan description for the full scope of coverage. In-network services are based on negotiated charges; Out-of-network services are based on a percentage of Medicare charges.
- *Includes Deductible and Copayments | After deductible | *Using UHC’s Designated Network will result in greater savings on these services.