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/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/health-insurance/resources/High-Deductible-Health-Plan-Benefit-Overview.pdf

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UWHC,UWMF,

Departments & Programs,UW Health,Benefits,UW Health Open Enrollment,UWMF Open Enrollment,Health Insurance,Resources

High Deductible Health Plan Benefit Overview

High Deductible Health Plan Benefit Overview - Departments & Programs, UW Health, Benefits, UW Health Open Enrollment, UWMF Open Enrollment, Health Insurance, Resources


!M!Y rn .... .;.;;;;;
Affiliated with UW Health
Annual Deductible
Coinsurance
Annual Maximum Out of Pocket
Lifetime Maximum
Annual Maximum for Essential Benefits
Preventive Services
Dependent Age
Physician Services
Office Visit
Chiropractor Visits
Hearing Examination
Podiatry Services
Vision Services
Weight Loss/Nutritional Counseling
Hospital Services
General Inpatient
Delivery & Newborn Charges
Outpatient Services
Emergency Services
Emergency Room
Urgent Care
Ambulance
Pharmacy Benefits
Tier 1 /Tier 2/Tier 3
Max Out-of-Pocket (Single/Family)
Behavioral Health
Inpatient
Transitional
Outpatient
Psychiatrist or Psychologist
Other Mental Health Professional
Diagnostic Services
Lab
X-Ray
MRI/MRA Scan
PET Scan
CAT Scan
Other Services
Anesthesia for Dental
Autism Spectrum Disorder
Durable Medical Equipment
Home Health Care Services
Hospice Services
Kidney Disease Treatment
Oral Surgery
Skilled Nursing Care Facility
Therapy Services
TMJ Benefits
HMO Benefit Overview
UW MEDICAL FOUNDATION
$2,500/$5,000 (Single/Family)
0% Coinsurance
$2,500/$5,000 (Single/Family)
Unlimited
Unlimited
Unlimited
26/26
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Medical Max Out-of-Pocket
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
See Specific Benefit Category for Applicable Coverage
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
See Specific Benefit Category for Applicable Coverage
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
Subject to Deductible and Coinsurance
This Benefits Summary is intended to highlight the benefils provided in the Unity Health Plans HMO policy All benefits are subject to the terms of the
policy Please see your policy, including the Certificate of Coverage and Schedule of Benefits (SOB), for limitations and exclusions
High Deductible Health Plan (HDHP)
Effective 01/01/2018