Situation

CHOICE PLUS

NETWORK

CHOICE PLUS

NON-NETWORK

Anesthesia

Services provided by facility based RAPLEs (i.e., radiologists, anesthesiologists, pathologists, labs, emergency room physicians) are covered as part of the facility benefit as described under Hospital Inpatient Stay, Emergency Health Services or Outpatient Surgery categories. RAPL services associated with outpatient lab/diagnostics are described under the Outpatient Diagnostic benefit.

Eye Examinations

Eye examinations received from a health care provider in the provider's office.

$35 copay per visit then 100% of eligible expenses.

Benefits include one routine vision exam, including refraction, to detect vision impairment by a Network Provider every Calendar Year.

Please note that Benefits are not available for charges connected to the purchase or fitting of eyeglasses or contact lenses.

80% of eligible expenses after satisfying $300 deductible.

Please note that Benefits are not available for charges connected to the purchase or fitting of eyeglasses, contact lenses, routine vision exams, including refraction to detect vision impairment by a Non-Network Provider.

Hearing Care

$35 copay per visit then 100% of eligible expenses.

Benefits include one routine hearing exam, by a Network Provider every Calendar Year.

Hearing Aids

90% of eligible expenses.

$5,000 maximum benefit every 3 years.

80% of eligible expenses after satisfying $300 deductible.

Hearing Aids

80% of eligible expenses after satisfying $300 deductible.

$5,000 maximum benefit every 3 years.

Injections received in a Physician's Office

Benefits are available for injections received in a Physician’s office when no other health service is received.

$20 copay per visit then 100% of eligible expenses.

No Copayment applies when a Physician charge is not assessed.

80% of eligible expenses after satisfying $300 deductible.

Nutritional Counseling

Covered Health Services provided by a registered dietician in an individual session for Covered Persons with medical conditions that require a special diet. Some examples of such medical conditions include:

●  Diabetes mellitus;

●  Coronary artery disease;

●  Congestive heart failure;

●  Severe obstructive airway disease;

●  Gout;

●  Renal failure;

●  Phenylketonuria; and

●  Hyperlipidemias.

The following services are not covered:

●  Nutritional counseling for either individuals or groups, except as described above;

●  Megavitamin and nutrition based therapy;

●  Food of any kind even if it is the only source of nutrition or unless it is specifically created to treat inborn errors of metabolism such as phenylketonuria (PKU). Foods that are not covered include:

●  Enteral feedings and

other nutritional and electrolyte formulas, including infant formula and donor breast milk;

●  Foods to control weight, treat obesity (including liquid diets), lower cholesterol or control diabetes;

●  Oral vitamins and

minerals;

●  Meals you can order

from a menu, for an additional charge, during an Inpatient Stay; and

●  Other dietary and

electrolyte supplements; and

●  Health club memberships

and programs, and spa treatments; and

●  Health education classes

unless offered by UnitedHealthcare or its affiliates, including but not limited to asthma, smoking cessation, and weight control classes.

$35 copay per visit then 100% of eligible expenses.

Benefits are limited to three individual sessions during a Covered Person’s lifetime for each medical condition.

80% of eligible expenses after satisfying $300 deductible.

Benefits are limited to three individual sessions during a Covered Person’s lifetime for each medical condition.

Physician's Office Services

Covered Health Services received in a Physician’s office include:

●  Evaluation and treatment of Sickness or Injury provided by a general pediatrician, internists, family practitioner or general practitioner;

●  Vision and hearing

screenings (vision screenings do not include refractive eye examinations to detect vision impairment.  See Eye Examinations).

$20 copay per visit then 100% of eligible expenses.

No copayment applies when no Physician charge is assessed.

Biofeedback:

Benefits are provided for short-term biofeedback training services provided in a Physician's office.  Benefits are limited to the treatment of headaches.

80% of eligible expenses after satisfying $300 deductible.

Biofeedback:

Benefits are provided for short-term biofeedback training services provided in a Physician's office.  Benefits are limited to the treatment of headaches.

Physician’s Office Services – Specialist

Covered Health Services given by a licensed Physician or other health care professional other than the Covered Person’s primary Physician.  A specialist is a Physician who has a majority of his or her practice in areas other than general pediatrics, internal medicine, obstetrics/gynecology, family practice or general medicine.

$35 copay per visit then 100% of eligible expenses.

80% of eligible expenses after satisfying $300 deductible.

Preventive Care

The Plan will pay Benefits for the Covered Health Services listed below, as well as preventive care services for which your Physician documents the need based on your family or medical history.

Children under Age 18:

·  One Routine Physical per Calendar Year year;

·  Phenylketonuria (PKU) tests and;

·  Immunizations.

·  Annual flu shot.

Women:

·  One routine Gynecological exam per Calendar Year including breast and pelvic examination, treatment of minor infections, and PAP test.

Men:

·  PSA blood test and digital rectal exam annually, beginning at age 40.

Men and Women:

·  One routine physical per Calendar Year for ages 18 and above;

·  Colorectal cancer screening beginning at age 50; frequency of screening depends on the test performed.

·  Annual flu shot.

100% of eligible expenses.

80% of eligible expenses after satisfying $300 deductible.

Professional Fees for Surgical and Medical Services

Professional fees for surgical procedures and other medical care received in a Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility or Alternate Facility, outpatient surgery facility, or birthing center.

When these services are performed in a Physician's office, Benefits are described under Physician's Office Services.

90% of eligible expenses.

80% of eligible expenses after satisfying $300 deductible.

Second Surgical Opinion

This is not a required service to obtain benefits.

Physician Office Services:

$20 copay per visit then 100% of eligible expenses.

Specialist Office Services:

$35 copay per visit then 100% of eligible expenses.

80% of eligible expenses after satisfying $300 deductible.