| Medical | ||
| DEDUCTIBLE: | $5,000 | |
| COINSURANCE: | 100% | |
| OOP MAX: | $6,600 | |
| Plan Code: | AAC3 | |
| Plan Category: | Balanced | |
| Metallic Level: | Bronze | |
| Employer Contribution HRA/HSA: | 0.00 - 0.00 | |
| Plan Type: | UnitedHealthcare | |
| Product Type: | CHOICE PLUS | |
| License Type: | INS | |
| Office Copay: | 40 | |
| Office Coinsurance: | 1 | |
| Specialist Copay: | 50 | |
| Emergency Room: | 0 | |
| Urgent Care: | 0 | |
| In-network single deductible: | 5000 | |
| In-network family deductible: | 10000 | |
| Out-of-network single deductible: | 10000 | |
| Out-of-network family deductible: | 20000 | |
| In-network Coinsurance: | 0.6 | |
| Out-of-network Coinsurance: | 0.5 | |
| In-network single Out-of-pocket Max: | 6600 | |
| In-network family Out-of-pocket Max: | 13200 | |
| Out of Network single Out-of-pocket Max: | 13200 | |
| Out-of-Network family Max: | 26400 | |
| Combined Med & Rx Deductible: | Y | |
| Embedded Deductible: | N | |
| Platform Identifier: | PRIME | |
| Rx Plans | ||
| 094: | Y | |
(S): This plan features split physician office visit copayments. Enrollees in these plans will pay a higher copayment when they see specialists than when they see primary care physicians.
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