What comes out of my pay?How much will I pay out of my own pocket?What is Venafi contributing?What will I pay after I meet my deductible?Will my doctor be in-network?
Network Options: UHC Options PPO (Utah Only), UHC Choice Plus, and Kaiser Permanente (California Only)
You’ve built a trusting relationship and you want to keep it. But, did you know that you can also save money by using an in-network provider? That’s why you will be able to choose a provider network that is right for you and your family’s health and wellbeing.
(866) 873-3903 | myuhc.com
(833) 574-2273 | healthy.kaiserpermanente.org – California only
Medical Plans
UNITED HEALTHCARE
TRADITIONAL COPAY PLAN
OPTIONS PPO NETWORK
TRADITIONAL COPAY PLAN
OPTIONS PPO NETWORK
UNITED HEALTHCARE
HIGH DEDUCTIBLE HEALTH PLAN
OPTIONS PPO NETWORK
HIGH DEDUCTIBLE HEALTH PLAN
OPTIONS PPO NETWORK
In-Network
In-Network
Annual Deductible
You pay up to
$1,000 for single coverage
$2,000 per family
Embedded
$1,000 for single coverage
$2,000 per family
Embedded
You pay up to
$2,000 for single coverage
$4,000 per family
Non-embedded
$2,000 for single coverage
$4,000 per family
Non-embedded
Accumulator Period
January 1 – December 31
January 1 – December 31
Coinsurance
You pay 20% AD
You pay 20% AD
Out-of-pocket Maximum
No more than
$3,000 for single coverage
$3,000 per member / $6,000 per family
Embedded
$3,000 for single coverage
$3,000 per member / $6,000 per family
Embedded
No more than
$4,000 per individual
$8,000 per family
Non-embedded
$4,000 per individual
$8,000 per family
Non-embedded
Preventive Services
You pay $0 according to government guidelines
You pay $0 according to government guidelines
Office Visits
Primary Care
Specialist
Specialist
You pay $25 copay
You pay $45 copay
You pay $45 copay
You pay 20% AD
You pay 20% AD
You pay 20% AD
Mental Health Services
Office Visit
Inpatient
Inpatient
You pay $25 copay
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
Emergency Services
Urgent Care
Emergency Room
Emergency Room
You pay $45 copay
You pay $150 copay + 20% AD
You pay $150 copay + 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
Inpatient & Outpatient
Inpatient Hospital
Outpatient Surgery
Outpatient Surgery
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
Prescription Medication
Generic / Preferred Brand / Non-preferred Brand
Generic / Preferred Brand / Non-preferred Brand
Retail (30-day supply)
Mail Order (90-day supply)
Mail Order (90-day supply)
You pay $15 / $40 / $60
You pay $37.50 / $100 / $150
You pay $37.50 / $100 / $150
You pay 20% AD / 20% AD / 20% AD
You pay 20% AD
You pay 20% AD
Health Care Account
Flexible Spending Account (FSA)
Health Savings Account (HSA)
Limited Purpose Flexible Spending Account (LPFSA)
Limited Purpose Flexible Spending Account (LPFSA)
AD: After Deductible
* Providers may charge more than the plan allows when you receive services out-of-network. It is recommended that you ask the out-of-network provider about their billed charges before planning care.
1 Standard Plans Managed Choice POS Network
* Providers may charge more than the plan allows when you receive services out-of-network. It is recommended that you ask the out-of-network provider about their billed charges before planning care.
1 Standard Plans Managed Choice POS Network
UNITEDHEALTHCARE TRADITIONAL COPAY PLAN
UNITEDHEALTHCARE HIGH DEDUCTIBLE HEALTH PLAN
VENAFI PREMIUM COST
VENAFI PREMIUM COST
Team Member Premium
Monthly
Annually
Monthly
Annually
Team Member (TM) Only
$0.00
$673.71
$8,084.52
$548.53
$6,582.36
TM + Spouse / Domestic Partner
$0.00
$1,489.71
$17.876.52
$1,212.84
$14,554.08
TM + Child(ren)
$0.00
$1,422.37
$17,068.44
$1,158.06
$13,896.72
TM + Family
$0.00
$2,103.32
$25,239.84
$1,712.40
$20,548.80
UNITED HEALTHCARE
TRADITIONAL COPAY PLAN
CHOICE PLUS PPO NETWORK
TRADITIONAL COPAY PLAN
CHOICE PLUS PPO NETWORK
UNITED HEALTHCARE
HIGH DEDUCTIBLE HEALTH PLAN
CHOICE PLUS NETWORK
HIGH DEDUCTIBLE HEALTH PLAN
CHOICE PLUS NETWORK
KAISER PERMANENTE
HMO PLAN
KAISER NETWORK
HMO PLAN
KAISER NETWORK
In-Network
In-Network
In-Network Only
Annual Deductible
You pay up to
$1,000 for single coverage
$1,000 per member / $2,000 per family
Embedded
$1,000 for single coverage
$1,000 per member / $2,000 per family
Embedded
You pay up to
$2,000 for single coverage
$4,000 per family
Non-embedded
$2,000 for single coverage
$4,000 per family
Non-embedded
You pay up to
$1,000 for single coverage
$1,000 per member / $2,000 per family
Embedded
$1,000 for single coverage
$1,000 per member / $2,000 per family
Embedded
Accumulator Period
January 1 – December 31
January 1 – December 31
January 1 – December 31
Coinsurance
You pay 20% AD
You pay 20% AD
You pay 20% AD
Out-of-pocket Maximum
No more than
$3,000 for single coverage
$3,000 per member / $6,000 per family
Embedded
$3,000 for single coverage
$3,000 per member / $6,000 per family
Embedded
No more than
$4,000 per individual
$8,000 per family
Non-embedded
$4,000 per individual
$8,000 per family
Non-embedded
No more than
$3,000 for single coverage
$3,000 per member / $6,000 per family
Embedded
$3,000 for single coverage
$3,000 per member / $6,000 per family
Embedded
Preventive Services
You pay $0 according to government guidelines
You pay $0 according to government guidelines
You pay $0 according to government guidelines
Office Visits
Primary Care
Specialist
Specialist
You pay $25 copay
You pay $45 copay
You pay $45 copay
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay $30 copay
You pay $30 copay
You pay $30 copay
Mental Health Services
Office Visit
Inpatient
Inpatient
You pay $25 copay
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay $30 copay
You pay 20% AD
You pay 20% AD
Emergency Services
Urgent Care
Emergency Room
Emergency Room
You pay $45 copay
You pay $150 copay + 20% AD
You pay $150 copay + 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay $30 AD
You pay 20% AD
You pay 20% AD
Inpatient & Outpatient
Inpatient Hospital
Outpatient Surgery
Outpatient Surgery
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
Prescription Medication
Generic / Preferred Brand / Non-preferred Brand
Generic / Preferred Brand / Non-preferred Brand
Most Generics / Most Brands / Most Specialty
Pharmacy Deductible
Retail (30-day supply)
Mail Order (90-day supply)
Retail (30-day supply)
Mail Order (90-day supply)
None
You pay $15 / $40 / $60
You pay $37.50 / $100 / $150
You pay $15 / $40 / $60
You pay $37.50 / $100 / $150
None
You pay 20% AD / 20% AD / 20% AD
You pay 20% AD
You pay 20% AD / 20% AD / 20% AD
You pay 20% AD
$250 per member
You pay $10** / $30** APD / 20%*** APD
You pay $10** / $30** APD / 20%*** APD
Health Care Account
Flexible Spending Account (FSA)
Health Savings Account (HSA)
Limited Purpose Flexible Spending Account (LPFSA)
Limited Purpose Flexible Spending Account (LPFSA)
Flexible Spending Account (FSA)
AD: After Deductible
APD: After Pharmacy Deductible
** For up to a 100-day supply
*** For up to a 30-day supply — not to exceed $200
APD: After Pharmacy Deductible
** For up to a 100-day supply
*** For up to a 30-day supply — not to exceed $200
UNITEDHEALTHCARE TRADITIONAL COPAY PLAN
UNITEDHEALTHCARE HIGH DEDUCTIBLE HEALTH PLAN
KAISER PERMANENTE - HMO PLAN
VENAFI PREMIUM COST
VENAFI PREMIUM COST
VENAFI PREMIUM COST
Team Member Premium
Monthly
Annually
Monthly
Annually
Monthly
Annually
Team Member (TM) Only
$0.00
$647.79
$7,773.48
$527.43
$6,329.16
$584.43
$7,013.16
TM + Spouse / Domestic Partner
$0.00
$1,432.41
$17,188.92
$1,166.19
$13,994.28
$1,291.59
$15,499.08
TM + Child(ren)
$0.00
$1,367.67
$16,412.04
$1,113.53
$13,362.36
$1,233.15
$14,797.80
TM + Family
$0.00
$2,022.42
$24,269.04
$1,646.54
$19,758.48
$1,823.43
$21,881.16
UNITED HEALTHCARE
TRADITIONAL COPAY PLAN
CHOICE PLUS PPO NETWORK
TRADITIONAL COPAY PLAN
CHOICE PLUS PPO NETWORK
UNITED HEALTHCARE
HIGH DEDUCTIBLE HEALTH PLAN
CHOICE PLUS PPO NETWORK
HIGH DEDUCTIBLE HEALTH PLAN
CHOICE PLUS PPO NETWORK
In-Network
In-Network
Annual Deductible
You pay up to
$1,000 for single coverage
$2,000 per family
Embedded
$1,000 for single coverage
$2,000 per family
Embedded
You pay up to
$2,000 for single coverage
$4,000 per family
Non-embedded
$2,000 for single coverage
$4,000 per family
Non-embedded
Accumulator Period
January 1 – December 31
January 1 – December 31
Coinsurance
You pay 20% AD
You pay 20% AD
Out-of-pocket Maximum
No more than
$3,000 for single coverage
$3,000 per member / $6,000 per family
Embedded
$3,000 for single coverage
$3,000 per member / $6,000 per family
Embedded
No more than
$4,000 per individual
$8,000 per family
Non-embedded
$4,000 per individual
$8,000 per family
Non-embedded
Preventive Services
You pay $0 according to government guidelines
You pay $0 according to government guidelines
Office Visits
Primary Care
Specialist
Specialist
You pay $25 copay
You pay $45 copay
You pay $45 copay
You pay 20% AD
You pay 20% AD
You pay 20% AD
Mental Health Services
Office Visit
Inpatient
Inpatient
You pay $25 copay
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
Emergency Services
Urgent Care
Emergency Room
Emergency Room
You pay $45 copay
You pay $150 copay + 20% AD
You pay $150 copay + 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
Inpatient & Outpatient
Inpatient Hospital
Outpatient Surgery
Outpatient Surgery
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
You pay 20% AD
Prescription Medication
Generic / Preferred Brand / Non-preferred Brand
Generic / Preferred Brand / Non-preferred Brand
Retail (30-day supply)
Mail Order (90-day supply)
Mail Order (90-day supply)
You pay $15 / $40 / $60
You pay $37.50 / $100 / $150
You pay $37.50 / $100 / $150
You pay 20% AD / 20% AD / 20% AD
You pay 20% AD
You pay 20% AD
Health Care Account
Flexible Spending Account (FSA)
Health Savings Account (HSA)
Limited Purpose Flexible Spending Account (LPFSA)
Limited Purpose Flexible Spending Account (LPFSA)
AD: After Deductible
* Providers may charge more than the plan allows when you receive services out-of-network. It is recommended that you ask the out-of-network provider about their billed charges before planning care.
1 Standard Plans Managed Choice POS Network
* Providers may charge more than the plan allows when you receive services out-of-network. It is recommended that you ask the out-of-network provider about their billed charges before planning care.
1 Standard Plans Managed Choice POS Network
UNITEDHEALTHCARE TRADITIONAL COPAY PLAN
UNITEDHEALTHCARE HIGH DEDUCTIBLE HEALTH PLAN
VENAFI PREMIUM COST
VENAFI PREMIUM COST
Team Member Premium
Monthly
Annually
Monthly
Annually
Team Member (TM) Only
$0.00
$647.79
$7,773.48
$527.43
$6,329.16
TM + Spouse / Domestic Partner
$0.00
$1,432.41
$17,188.92
$1,166.19
$13,994.28
TM + Child(ren)
$0.00
$1,367.67
$16,412.04
$1,113.53
$13,362.36
TM + Family
$0.00
$2,022.42
$24,269.04
$1,646.54
$19,758.48
Venafi Health Savings Account Contributions
VENAFI HSA CONTRIBUTIONS
IRS Annual Maximum
Monthly
Annually
Team Member (TM) Only
$3,600.00
$100.00
$1,200.00
TM + Spouse / Domestic Partner
$7,200.00
$208.33
$2,500.00
TM + Child(ren)
$7,200.00
$208.33
$2,500.00
TM + Family
$7,200.00
$266.67
$3,200.00
Medical Opt Out Options
Who is waiving?
What are you eligible for?
Monthly Amount
Just myself
Single
$100
Myself & my spouse
Team Member + Spouse
$200
Myself & my children
Team Member + Child(ren)
$200
Myself & my entire family
Team Member + Family
$250
Only my spouse
Team Member + Spouse
$100
Only my child(ren)
Family
$100
My spouse & my child(ren)
Family
$200
