United Healthcare PPO $2,500
Medical benefits are provided through United Healthcare and Kaiser. Consider the physician networks, premiums, and out-of-pocket costs for each plan when choosing for you and your family.
United Healthcare PPO $2,500
Plan details
- Carrier
- United Healthcare
- Plan Type
- PPO
- Network
- New in 2027, the United Healthcare network will be the Core network.
- Out-of-Network Coverage
- Yes
| Coverage tier | BIWEEKLY CONTRIBUTIONS |
|---|---|
| Employee Only | $95.37 |
| Employee + Spouse | $199.95 |
| Employee + Child(ren) | $181.76 |
| Employee + Family | $272.66 |
Employee Only
- BIWEEKLY CONTRIBUTIONS
- $95.37
Employee + Spouse
- BIWEEKLY CONTRIBUTIONS
- $199.95
Employee + Child(ren)
- BIWEEKLY CONTRIBUTIONS
- $181.76
Employee + Family
- BIWEEKLY CONTRIBUTIONS
- $272.66
| Benefit | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Annual Deductible - Individual | $2,500 | $5,000 |
| Annual Deductible - Family | $5,000 | $10,000 |
| Coinsurance (Plan Pays) | 60%* | 50%* |
| Annual Out-Of-Pocket Maximum (Maximum Includes Deductible) - Individual | $9,000 | $18,000 |
| Annual Out-Of-Pocket Maximum (Maximum Includes Deductible) - Family | $18,000 | $36,000 |
| Preventive Care | 100% | Not covered |
| Primary Care | $60 copay | 50%* |
| Specialist Services | $90 copay | 50%* |
| Major Diagnostic Imaging | 60%* | 50%* |
| Inpatient | 60%* | 50%* |
| Urgent Care | $60 copay | 50%* |
| Emergency Room | 60%* | 60%* |
Annual Deductible - Individual
- IN-NETWORK
- $2,500
- OUT-OF-NETWORK
- $5,000
Annual Deductible - Family
- IN-NETWORK
- $5,000
- OUT-OF-NETWORK
- $10,000
Coinsurance (Plan Pays)
- IN-NETWORK
- 60%*
- OUT-OF-NETWORK
- 50%*
Annual Out-Of-Pocket Maximum (Maximum Includes Deductible) - Individual
- IN-NETWORK
- $9,000
- OUT-OF-NETWORK
- $18,000
Annual Out-Of-Pocket Maximum (Maximum Includes Deductible) - Family
- IN-NETWORK
- $18,000
- OUT-OF-NETWORK
- $36,000
Preventive Care
- IN-NETWORK
- 100%
- OUT-OF-NETWORK
- Not covered
Primary Care
- IN-NETWORK
- $60 copay
- OUT-OF-NETWORK
- 50%*
Specialist Services
- IN-NETWORK
- $90 copay
- OUT-OF-NETWORK
- 50%*
Major Diagnostic Imaging
- IN-NETWORK
- 60%*
- OUT-OF-NETWORK
- 50%*
Inpatient
- IN-NETWORK
- 60%*
- OUT-OF-NETWORK
- 50%*
Urgent Care
- IN-NETWORK
- $60 copay
- OUT-OF-NETWORK
- 50%*
Emergency Room
- IN-NETWORK
- 60%*
- OUT-OF-NETWORK
- 60%*
- *After deductible
| Benefit | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Annual Rx Deductible - Individual | $350 | $350 |
| Annual Rx Deductible - Family | $700 | $700 |
| Retail Rx (31-Day Supply) - Tier 1 | $25 copay* | Not covered |
| Retail Rx (31-Day Supply) - Tier 2 | $80 copay* | Not covered |
| Retail Rx (31-Day Supply) - Tier 3 | $110 copay* | Not covered |
| Retail Rx (31-Day Supply) - Tier 4 | 70% to a maximum of $250* | Not covered |
| Retail Rx (31-Day Supply) - Specialty | N/A | Not covered |
| Mail Order Rx (90-Day Supply) - Tier 1 | $62.50 copay* | Not covered |
| Mail Order Rx (90-Day Supply) - Tier 2 | $200 copay* | Not covered |
| Mail Order Rx (90-Day Supply) - Tier 3 | $275 copay* | Not covered |
| Mail Order Rx (90-Day Supply) - Tier 4 | 70% to a maximum of $250* | Not covered |
Annual Rx Deductible - Individual
- IN-NETWORK
- $350
- OUT-OF-NETWORK
- $350
Annual Rx Deductible - Family
- IN-NETWORK
- $700
- OUT-OF-NETWORK
- $700
Retail Rx (31-Day Supply) - Tier 1
- IN-NETWORK
- $25 copay*
- OUT-OF-NETWORK
- Not covered
Retail Rx (31-Day Supply) - Tier 2
- IN-NETWORK
- $80 copay*
- OUT-OF-NETWORK
- Not covered
Retail Rx (31-Day Supply) - Tier 3
- IN-NETWORK
- $110 copay*
- OUT-OF-NETWORK
- Not covered
Retail Rx (31-Day Supply) - Tier 4
- IN-NETWORK
- 70% to a maximum of $250*
- OUT-OF-NETWORK
- Not covered
Retail Rx (31-Day Supply) - Specialty
- IN-NETWORK
- N/A
- OUT-OF-NETWORK
- Not covered
Mail Order Rx (90-Day Supply) - Tier 1
- IN-NETWORK
- $62.50 copay*
- OUT-OF-NETWORK
- Not covered
Mail Order Rx (90-Day Supply) - Tier 2
- IN-NETWORK
- $200 copay*
- OUT-OF-NETWORK
- Not covered
Mail Order Rx (90-Day Supply) - Tier 3
- IN-NETWORK
- $275 copay*
- OUT-OF-NETWORK
- Not covered
Mail Order Rx (90-Day Supply) - Tier 4
- IN-NETWORK
- 70% to a maximum of $250*
- OUT-OF-NETWORK
- Not covered
- *After deductible
Plan Notes
- You’ll pay more in premiums, but perhaps less at the time of service.
- You can choose from a network of providers who offer a fixed copay for office visits.
- If you expect to need more medical care this year or you have a chronic illness, the PPO may be the right choice for you to ensure your healthcare needs are covered.