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):
 
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 for medical emergencies and accidental injuries
$150 copayment
$150 copayment
$150 copayment
$150 copayment
$150 copayment
 
Emergency room for non-emergency conditions
Not covered
Not covered
Not covered
Not covered
 
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 in "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 - BRCA 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%
 
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
Ambulance*
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.
Non-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.
Non-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 $10,000 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 LifeWorks 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 LifeWorks at 888 267 8126.
* In general, 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):
 
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 for medical emergencies and accidental injuries
20%
20%
30%
30%
Emergency room for non-emergency conditions
Not covered
Not covered
Not covered
Not covered
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 in "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, 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
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 - BRCA 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%
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*
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 $10,000 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%
* In general, 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.