Medical office, phone, & video visits1
At UHS: $15 co-pay for primary care, physical therapy and gynecology. $25 co-pay for specialists.
Outside of UHS:
Pays 100% after $15 co-pay for primary care and $25 for specialty care from in-network providers. Plan pays 50%2 of the allowable non-network rates.
Note: If the visit is at a hospital setting, a facility (hospital) fee may apply. After the deductible, plan pays 90% for network rates or 50% non-network rates.
Adult preventative services
Select adult preventative services at UHS (including routine mammograms, pap smears and prostate cancer screenings as determined necessary by your provider) covered at 100% (only one per plan year).
Lab tests, x-rays, imaging, mammograms
At UHS: Pays 90% of UHS fees.
Outside of UHS2: Pays 90% of network rates or 50% of non-network rates.
Prenatal care, maternity, newborn, breast pump, abortion
Prenatal: Plan pays 100% in-network or 50%
2 non-network.
Maternity: See our maternity flier. If you wish to see a midwife, see our
list of in-network midwives. (Note: This provider list is only periodically updated. Please confirm that your midwife is still in-network prior to receiving services.)
Newborns are covered for the first 31 days from the date of birth. Plan pays 100% for newborn well visits in-network. Plan pays 90% in-network or 50% non-network for sickness or injury after a separate $450 deductible is met)
3
Breast Feeding Durable Medical Equipment: Pays 100% in-network or 50%
2 non-network.
Abortion: Pays100% in-network or 50%
2 non-network.
Acupuncture4
Pays 100% after $25 co-pay or 50%2 of non-network rates.
Chiropractic Services4
Pays 100% after $25 co-pay or 50%2 of non-network rates.
Podiatric Services2
Pays 90% of network rates or 50% of non-network rates.
Physical Therapy4
At UHS: $15 co-pay
Outside of UHS: Pays 100% after $15 co-pay for network rates or 50%2 of non-network rates.
Occupational and Speech Therapy4
Pays 100% after $15 copay or 50%2 of non-network rates.
Allergy Testing & Injections
At UHS: Pays 90% of network rates or 50%2 of non-network rates.
Outside of UHS2: Pays 90% of network rates or 50% of non-network rates.
UHS does not provide allergy testing services.
Immunizations
Pays 100% UHS charges or network rates, or 50%2 of non-network rates, for the following immunizations:
Diphtheria/Tetanus/ Pertussis, Measles, Mumps and Rubella; Meningococcal; Varicella; Influenza; Hepatitis A and Hepatitis B; Pneumococcal; Polio; Human Papillomavirus; Cholera; Typhoid; Yellow Fever; Japanese B. Encephalitis; and Lyme Vaccine. TB testing/screening covered 100%.
All other immunizations covered at 90% of charge at UHS or 90%2 of network rates or 50%2 of non-network rates.
NOTE: Routine immunizations are recommended to be administered at UHS. All immunizations must meet all FDA regulations prior to approval.
Home Health Visits2
Pays 90% of network rates or 50% of non-network rates.
Skilled Nursing Facility2
Pays 90% of network rates or 50% of non-network rates.
Durable Medical Equipment1, 2
Pays 90% of network rates or 50% of non-network rates for the rental or purchase of medical equipment and supplies that are ordered by a physician and are of no further use when medical need ends. For breast pump coverage, please see maternity benefits.
Equipment must be obtained from a durable medical equipment supplier, including rental or purchase of diabetic equipment and supplies (excluding insulin).
