7/27/2019 ASHA UHC Plan Comparison for 2014
1/1
ChoiceNetwork Only
MEDICAL BENEFIT SYNOPSIS Network Network Non-Network Network
Non-Network
DeductibleIndividual None None $500 $2,000 $4,000
Family None None $1,000 $4,000 $8,000
Health Savings Account (HSA) Not Applicable
Employee Coinsurance 0% 0% 20% 0% 20%
Plan Coinsurance 100% 100% 80% 100% 80%
Max Out-of-Pocket (includes Deductible) Calendar Year
Individual $2,500 $2,500 $2,500 $3,000 $8,000
Family $5,000 $5,000 $5,000 $6,000 $16,000
Doctor Visit Copay (PCP/Specialist) $15/$25 copay $15/$15 copay
Ded, then 20% No copay - Ded, then 0% Ded, then 20%
Convenience Care Centers $15 copay $15 copay Ded, then 20% Ded,
then 0% Ded, then 20%
Urgent Care Center $50 copay $50 copay Ded, then 20% Ded, then
0% Ded, then 20%
Emergency Room (True Emergency) $100 copay Ded, then 0% Ded,
then 0%
Preventive Care Services 0% 0% Ded, then 20% 0% Ded, then
20%
Lab, X-ray and Major Diagnostics 0% 0% Ded, then 20% Ded, then
0% Ded, then 20%
Hospital Copay/Deductible: 0% 0% Ded, then 20% Ded, then 0% Ded,
then 20%
Pre-certification required for all in-patient
stays
OutPatient Copay/Deductible: 0% 0% Ded, then 20% Ded, then 0%
Ded, then 20%
Rehabilitation Services $15 copay $15 copay Ded, then 20% Ded,
then 0% Ded, then 20%
Chiropractic treatment 30 visits per year
Physical Therapy Unlimited visits
Occupational Therapy Unlimited visits
Pulmonary Rehabilitation Unlimited visits
Cardiac Rehabilitation Unlimited visits
ASHA Model Hearing Benefits IncludedSpeech Therapy Unlimited
visits
Durable Medical Equipment 0% 0% Ded, then 20% Ded, then 0% Ded,
then 20%
Pre-service notification is required for DME and
Diabetes equipment in excess fo $1,000.
Prescription Card Benefit No Deductible
Retail: Generic/Formulary/NonFormulary $10/$35/$60 for 31 day
supply
Mail Order: $20/$70/$120 for 90 day supply
30 visits per year
Unlimited visits
Unlimited visits
Unlimited visits
$10/$35/$60 for 31 day supply
$20/$70/$120 for 90 day supply
Unlimited visits
$10/$35/$60 for 31 day supply
$20/$70/$120 for 90 day supply
No Deductible Subject to Calendar Year Deductible
Unlimited visitsIncluded Included
Unlimited visits
All Rx Copayments accumulate towards the Ou
Pocket Maximum
30 visits per year
Unlimited visits
Unlimited visits
Unlimited visits
Unlimited visits
No one in the family is eligible for benefits until
family deductible has been met. In and out-of-ne
deductibles do not cross accumulate.
Calendar Year
UNITED HEALTHCARE PLAN COMPARISON
Effective JANUARY 2014
AMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION
Choice PlusPREPARED BYUNITED HEALTHCARE
NEW Choice Plus with HSA
Calendar Year
Calendar Year
$100 copay
Not Applicable ASHA HSA Contribution
$1,000 individual coverage
$2,000 individual plus dependent coverag
Calendar Year
