Medical Benefits

Name: Hickerson's CATV
Address: United States

	In-Network
Deductible (Individual/Family)	$2,500/$5,000
Out-of-Pocket Max (Individual/Family)	$5,000/$10,000
Coinsurance	100%
Routine Preventive Care	No Copay
Primary Care Visit	Persons < 19: No Copay All others: $25 Copay
Specialist Visit	$75 Copay
Telehealth	Covered at same cost share as in-office
Inpatient Hospitalization	Deductible
Physician Services	Deductible
Outpatient Surgery	Deductible
Outpatient Basic Diagnostics	Deductible
Urgent Care	$50 Copay
Emergency Room	$300 Copay, then Deductible

	In-Network
Deductible (Individual/Family)	$3,000/$6,000
Out-of-Pocket Max (Individual/Family)	$5,500/$11,000
Coinsurance	100%
Routine Preventive Care	No Copay
Primary Care Visit	Persons < 19: No Copay All others: $25 Copay
Specialist Visit	$75 Copay
Telehealth	Covered at same cost share as in-office
Inpatient Hospitalization	Deductible
Physician Services	Deductible
Outpatient Surgery	Deductible
Outpatient Basic Diagnostics	Deductible
Urgent Care	$50 Copay
Emergency Room	$300 Copay, then Deductible

	In-Network
Deductible (Individual/Family)	$3,500/$7,000
Out-of-Pocket Max (Individual/Family)	$6,000/$12,000
Coinsurance	100%
Routine Preventive Care	No Copay
Primary Care Visit	Persons < 19: No Copay All others: $25 Copay
Specialist Visit	$75 Copay
Telehealth	Covered at same cost share as in-office
Inpatient Hospital	Deductible
Physician Services	Deductible
Outpatient Surgery	Deductible
Outpatient Basic Diagnostics	Deductible
Urgent Care	$50 Copay
Emergency Room	$300 Copay, then Deductible

Provided By

UnitedHealthcare

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