PPO $1,000

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: PPO
Network: UHC Choice Plus
Has Out Of Network Coverage: Yes
HSA Eligible: No
FSA Eligible: -
Employer Account Contribution: Not Eligible

Premiums (Bi-Weekly)

Coverage Tier	You Pay	NOVA Pays
Employee	$64.48	$399.39
Employee + Spouse	$282.95	$644.76
Employee + Child(ren)	$262.64	$618.69
Family	$385.00	$774.64

Employee

You Pay: $64.48
NOVA Pays: $399.39

Employee + Spouse

You Pay: $282.95
NOVA Pays: $644.76

Employee + Child(ren)

You Pay: $262.64
NOVA Pays: $618.69

Family

You Pay: $385.00
NOVA Pays: $774.64

Medical Services

	In-network	Out-of-network
Annual deductible (Individual/Family)	$1,000 / $2,000	$2,000 / $4,000
Embedded / Non-Embedded	Embedded	Embedded
Out-of-pocket maximum (Individual/Family)*	$2,000 / $4,000	$4,000 / $8,000
Preventive care	No Copay	30%
Primary physician office visit	$25 Copay	40%
Specialist office visit	$50 Copay	40%
Virtual Care	PCP: $25 Copay Specialist: $50 Copay	30%
Inpatient hospital services	20%	40%
Outpatient hospital services (lab*, x-ray, diagnostic)	$25 Copay	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	$50 Copay	40%
Emergency room care	$250 Copay	$250 Copay
Annual Health Savings Account (HSA) Employer Contributions	Not Eligible	Not Eligible

Annual deductible (Individual/Family)

In-network: $1,000 / $2,000
Out-of-network: $2,000 / $4,000

Embedded / Non-Embedded

In-network: Embedded
Out-of-network: Embedded

Out-of-pocket maximum (Individual/Family)*

In-network: $2,000 / $4,000
Out-of-network: $4,000 / $8,000

Preventive care

In-network: No Copay
Out-of-network: 30%

Primary physician office visit

In-network: $25 Copay
Out-of-network: 40%

Specialist office visit

In-network: $50 Copay
Out-of-network: 40%

Virtual Care

In-network: PCP: $25 Copay Specialist: $50 Copay
Out-of-network: 30%

Inpatient hospital services

In-network: 20%
Out-of-network: 40%

Outpatient hospital services (lab*, x-ray, diagnostic)

In-network: $25 Copay
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: $50 Copay
Out-of-network: 40%

Emergency room care

In-network: $250 Copay
Out-of-network: $250 Copay

Annual Health Savings Account (HSA) Employer Contributions

In-network: Not Eligible
Out-of-network: Not Eligible

*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

Plan Notes

We are pleased to introduce a new PPO (copay) plan, which will replace the HRA plan.
This plan is not eligible for a Health Savings Account (HSA), so there is no employer HSA contribution.