UHC Medical Plan – POS Gold Choice Plus HSA – Summary of Benefits

1. Overview

The UnitedHealthcare POS Gold Choice Plus HSA plan offers comprehensive medical coverage with both in‑network and out‑of‑network benefits. This is an HSA‑compatible plan with moderate deductibles, flexible provider access, and predictable copays for routine care.

Employees may see specialists without a referral, and coverage is highest when using in‑network providers.

2. Key Plan Features

Plan Type

• POS (Point of Service)
• In‑network and out‑of‑network coverage
• No referral required for specialists
• HSA‑compatible

Provider Network

• Uses the UnitedHealthcare Choice Plus network
• Out‑of‑network services covered at higher cost

3. Deductibles & Out‑of‑Pocket Costs

Annual Deductible

Prescription Drug Deductible

• $350 Individual / $700 Family
• Applies only to certain higher‑tier drugs (Tiers 3 & 4)

Out‑of‑Pocket Maximum

Not Included in Out‑of‑Pocket Limit

• Premiums
• Balance‑billing charges
• Non‑covered services
• Penalties for lack of preauthorization

4. Office Visits & Preventive Care

Primary Care

• $35 copay (in‑network)
• 50% coinsurance out‑of‑network

Specialist Visit

• $70 copay in‑network
• 50% coinsurance out‑of‑network

Preventive Care

• No charge in‑network
• Some preventive services covered out‑of‑network
• Must follow UHC preventive care guidelines

Virtual Visits

• No charge through designated virtual providers
• Out‑of‑network telehealth not covered

5. Diagnostic Testing & Imaging

Lab Work / X‑Rays

• 20% coinsurance in‑network
• 50% coinsurance out‑of‑network
• Out‑of‑network lab services may not be covered

CT, PET, MRI Imaging

• 20% coinsurance in‑network
• 50% coinsurance out‑of‑network
• Out‑of‑network imaging requires preauthorization

6. Prescription Drugs

Retail (31‑day supply) and Mail Order (90‑day supply)

Additional Rules

• Some drugs require preauthorization
• Specialty drugs must be filled through designated specialty pharmacies
• Preventive drugs and Tier 1 contraceptives may be available at no cost
• Using a non‑network pharmacy may result in higher costs or no coverage

7. Emergency & Urgent Care

Emergency Room

• 20% coinsurance (same in‑ or out‑of‑network)

Emergency Transportation

• 20% coinsurance

Urgent Care

• $50 copay in‑network
• 50% coinsurance out‑of‑network
• Additional services during visit may have additional costs

8. Hospitalization & Surgery

Outpatient Surgery

• 20% coinsurance in‑network
• 50% coinsurance out‑of‑network
• Out‑of‑network services require preauthorization

Inpatient Hospital

• 20% coinsurance in‑network
• 50% coinsurance out‑of‑network
• Preauthorization required for out‑of‑network stays

9. Mental Health & Substance Abuse

Outpatient Services

• $35 copay in‑network
• 50% coinsurance out‑of‑network
• Intensive programs may require coinsurance or preauthorization

Inpatient Services

• 20% coinsurance in‑network
• 50% coinsurance out‑of‑network

10. Maternity Care

Office Visits

• No charge for preventive prenatal care
• Cost‑share may apply for other services

Delivery

• 20% coinsurance for professional and facility services
• Out‑of‑network stays require preauthorization after certain lengths

11. Therapy, Rehab, and Skilled Care

Home Health Care

• 20% coinsurance
• Limited to 364 visits per year

Physical, Occupational & Speech Therapy

• $35 copay per visit in‑network
• 20‑visit annual limit per therapy type
• Unlimited cardiac & pulmonary rehab

Skilled Nursing Facility

• 20% coinsurance
• Up to 100 days per year

Durable Medical Equipment

• 20% coinsurance in‑network
• Not covered out‑of‑network

12. Pediatric Vision & Dental (Medical Plan Only)

Children’s Eye Exam

• $10 copay in‑network
• 1 exam per 12 months

Children’s Glasses

• $25 copay per frame
• One pair per year

Children’s Dental Cleanings

• 0% coinsurance in‑network
• 2 cleanings per 12 months

13. Excluded Services

Examples include:

• Adult dental
• Long‑term care
• Cosmetic surgery
• Routine foot care
• Weight‑loss programs
• Non‑emergency international care

14. Other Covered Services (with limits)

• Acupuncture (6 visits/year)
• Bariatric surgery
• Hearing aids
• Infertility treatment
• Private‑duty nursing
• Adult routine eye exam (1/year)
• Chiropractic care (20 visits/year)

15. Continuation of Coverage

Employees losing coverage may have access to:

• COBRA continuation benefits
• Marketplace plans

Assistance is available through state and federal agencies.