The following chart displays a comparison of plan provisions and benefits when seeing a participating provider1.
Printer Friendly| Plan Provisions | UHA 3000 | UHA 600 |
| Dependent child coverage | Up to age 26 | Up to age 26 |
| Annual Deductible2 | $200 per person $600 per family |
None |
| Annual Co-payment maximum | $2,500 per person $7,500 per family |
$2,500 per person $7,500 per family |
| Lifetime Maximum3 | Unlimited | Unlimited |
Medical Services |
UHA 3000 You Pay |
UHA 600 You Pay |
PREVENTIVE CARE SERVICES
UHA 3000 annual deductible does not apply to the following services
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| Physical exam (office visit) Once per calendar year |
No co-payment | No co-payment |
| Preventive screening services: Mammography, Pap Smear, PSA Test |
No co-payment | No co-payment |
| Well child care visit | No co-payment | No co-payment |
| Childhood Immunizations | No co-payment | No co-payment |
| Adult Immunizations | No co-payment | No co-payment |
| Laboratory | No co-payment | No co-payment |
MATERNITY SERVICES
UHA 3000 annual deductible does not apply to the following services
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| *Maternity care | No co-payment | 10% of EC |
| Birthing room | No co-payment | No co-payment |
| Newborn nursery | No co-payment | 10% of EC |
DISEASE MANAGEMENT PROGRAMS
UHA 3000 annual deductible does not apply to the following services
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| Smoking cessation | No co-payment | No co-payment |
| ** Nutrition counseling | No co-payment | No co-payment |
| Disease education | No co-payment | No co-payment |
PHYSICIAN SERVICES
UHA 3000 annual deductible does not apply to the following services
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| Physician office visit | $12 | 10% of EC |
| HOSPITAL SERVICES | ||
| Room & Board (semi-private room) | 20% of EC | 10% of EC |
| Ancillary Inpatient Services | 20% of EC | 10% of EC |
| Laboratory & pathology (inpatient) | 20% of EC | 10% of EC |
| EMERGENCY SERVICES | ||
| Emergency Room Services | 20% of EC | 10% of EC |
| Ambulance Services – Ground/Air | 20% of EC | 20% of EC |
COMPLIMENTARY ALTERNATIVE MEDICINE
UHA 3000 annual deductible does not apply to the following services
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| Chiropractic/Acupuncture Services | $10 co-payment per visit | |
| Benefits limited to treatment of conditions of the neuromusculoskeletal system by licensed providers |
First set of x-rays at 50% of EC; full charge for add’l sets; $500 combined maximum per calendar year |
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- The information above is intended to provide a condensed explanation of UHA medical plan benefits. Please refer to the appropriate Medical Benefits Guide (MBG) for complete information on benefits and provisions. In case of a discrepancy between this comparison and the language contained in the MBG, the MBG will take precedence.
- Annual deductible does not apply to all services. Refer to your Medical Benefits Guide to verify which services apply.
- Annual maximum of $2,000,000 per member per calendar year with no lifetime maximum.
EC = Eligible Charge. Refer to your Medical Benefits Guide for detailed definition.
*Covered, including prenatal, false labor, delivery, and postnatal services provided by your physician or midwife. Maternity care does not include related services such as nursery care, labor room, hospital room and board, diagnostic testing, and other lab work and radiology. Please refer to the specific benefits for more information on those services.
**Covered, but only when counseling is provided and Prior Authorization has been obtained, except where treatment is for diabetes. Please see Medical Benefits Guide for more information.
