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Primary Care Physician, OB/GYN, Pediatrician Office Visits
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Premium network: 100% after $15 copayment per visit
All other: 100% after $30 copayment per visit
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Preventive Care: benefits are based on recommendations from the United States Preventive Services Task Force, although other preventive care services recommended by your physician, based on your family or medical history, may be covered as well.
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100% after office visit copayment
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80% and a $75 copayment on MRIs' and other high-cost diagnostics
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Prenatal doctor office visits: 100% after $15 copayment per visit.
Inpatient delivery and associated hospital care: 80% coinsurance with $300 copayment.
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Prenatal doctor office visits: 60% after deductible.
Inpatient delivery and associated hospital care: 60% after deductible.
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100% with no copayment for recognized emergency care
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100% with no deductible for recognized emergency care
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$200 copayment for recognized emergency care (waived if admitted)
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$200 copayment for recognized emergency care (waived if admitted)
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Hospital Care (including surgery, room and board, semi-private rate, diagnostic testing)
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80% with authorization, for up to 60 visits per calendar year (including both in- and out-of-network visits).
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60% after deductible with authorization, for up to 60 visits per calendar year (including both in- and out-of-network visits).
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Physical and Occupational Therapy
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100% after $30 copayment per visit, for up to 30 visits per calendar year (including both in- and out-of-network visits).
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60% after deductible, for up to 30 visits per calendar year (including both in- and out-of-network visits).
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Chiropractic Care and Acupuncture
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100% after $30 copayment per visit, for up to 30 visits per calendar year (including both in- and out-of-network visits).
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60% after deductible, for up to 30 visits per calendar year (including both in- and out-of-network visits).
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Durable Medical Equipment
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80%; authorization required for equipment costing more than $2,000; rental up to purchase price.
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60% after deductible; authorization required for equipment costing more than $2,000; rental up to purchase price.
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100% if not included as part of an office visit; if administered during an office visit, 100% after $15 copayment for premium network physician or $30 for non-premium network physician
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80%, for up to 360 days of care per lifetime (including both in- and out-of-network care); respite care limited to up to 7 days of care (including both in- and out-of-network care).
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60% after deductible, for up to 360 days of care per lifetime (including both in- and out-of-network care); respite care limited to up to 7 days of care (including both in- and out-of-network care).
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80% with prior authorization only
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Not covered out-of-network
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Infertility Testing and Treatment of a Medical Condition Causing Infertility
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Fertility Treatments, with one year of service
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100%, with a $20,000 lifetime maximum when using United Healthcare's Centers of Excellence providers and facilities. Lifetime maximum is capped at $10,000 for services received from providers and facilities outside the United Healthcare Centers of Excellence network.
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Prescription Drugs (provided by Medco Health)
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Retail Pharmacy for up to one month's supply
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Tier 1 (generics): 90% coinsurance
Tier 2 (brand drugs without generic alternatives): 70% coinsurance
Tier 3 (brand drugs with generic alternatives): 50% coinsurance
$75 maximum per prescription
After three purchases (original prescription and two refills) for a maintenance medication at a retail pharmacy, you must use mail-order for all subsequent purchases of the same prescription or pay the full cost at a retail pharmacy.
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Mail Order for up to a 90-day supply
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Tier 1 (generics): 90% coinsurance
Tier 2 (brand drugs without generic alternatives): 70% coinsurance
Tier 3 (brand drugs with generic alternatives): 50% coinsurance
$150 maximum per prescription
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Mental Health/Substance Abuse (advance approval required for inpatient care provided by Value Options)
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EAP (Employee Assistance Program)
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5 visits paid at 100% per problem per year with an Employee Assistance Professional. Counseling beyond 5 visits with an EAP counselor is not a covered EAP benefit.
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No out of network EAP benefits.
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Inpatient: Pre-certification Required: 80% of ValueOptions (VO) fee schedule.
Outpatient: $15 copayment. Outpatient Treatment Report due after the 8th visit if therapy is to continue beyond 10 visits.
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Inpatient: Pre-certification Required: 60% of VO fee schedule.
Outpatient: 60% of VO fee schedule. Outpatient Treatment Report is due after the 26th visit if therapy is to continue beyond 26 visits
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Inpatient: Pre-certification Required: 80% of VO fee schedule.
Outpatient: $15 copayment. Outpatient Treatment Report is due after the 8th visit if therapy is to continue beyond 10 visits.
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Inpatient: Pre-certification Required: 60% of VO fee schedule.
Outpatient: 60% of VO fee schedule (including both in-network and out-of-network visits, combined with mental health). Outpatient Treatment Report is due after the 26th visit if therapy is to continue beyond 26 visits
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