Important Questions

Answers

Why This Matters:

What is the overall deductible?

Network: $2,000 individual / $4,000 family

Per calendar year. Does not apply to services listed below with copays or "No Charge." 

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

Yes, Prescription drugs for tiers 3 and 4 – $500 per person. There are no other deductibles.

You must pay all the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

Is there an out-of-pocket limit on my expenses?  

Yes. Network: $6,850 individual / $13,700 family

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services.
This limit helps you plan for health care expenses.

What is not included in the out-of-pocket limit?

Premiums, balance-billed charges and health care this plan doesn’t cover

Even though you pay these expenses, they don’t count toward the out-ofpocket limit.  

Is there an overall annual limit on what the plan pays?

No. 

The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. For a list of network providers, see uhc.com/find–a–physician/xilcompass or call 1-877-512-9940.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.  

Do I need a referral to see a specialist?

Yes. An electronic referral is required to see a Network Specialist 

This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan’s permission before you see the specialist.

Are there services this plan doesn’t cover?

Yes. 

Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services. 

Common 
Medical Event

Services You May Need

Your Cost If
You Use a
Network
Provider with a
Referral

Your Cost If
You Use a
Network
Provider without a
Referral

Your Cost If
You Use a
Out-ofNetwork
Provider

Limitations & Exceptions

If you visit a health care provider’s office
or clinic

Primary care visit to treat an injury or illness

$30 copay per
visit

Not Covered

Not Covered

Primary care provider (PCP) must be assigned. No referral required for
OB/GYN. Virtual visits
(Telehealth) – $25 copay per visit by a designated virtual network provider. 

Specialist visit

$60 copay per visit  

Not Covered

Not Covered

Referrals must be from assigned PCP.  

Other practitioner office visit

30% co-ins after deductible

Not Covered

Not Covered

Limited to 16 visits of manipulative (chiropractic) services per year.

Preventive care / screening / immunization

No Charge

Not Covered

Not Covered

Includes preventive health services. 

If you have a test

Diagnostic test (x-ray, blood work)

 Freestanding:
30% co-ins after deductible

 Freestanding:
30% co-ins after deductible

Not Covered

Hospital: 50% co-ins after deductible

Imaging (CT / PET scans, MRIs)

 30% co-ins after deductible

30% co-ins after deductible

Not Covered

Hospital: $400 imaging per occurrence. The $400 applies before the annual deductible.

If you need drugs to

Tier 1 – Your Lowest-Cost

Retail: $5 copay

Retail: $5 copay

Not Covered

Provider means pharmacy for

treat your illness or
condition

More information about prescription drug  coverage is available at
uhc.com/rxfind  

Option

purposes of this section. Retail: Up to a 31 day supply.
Mail-Order: Not Covered You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us.
Certain drugs may have a preauthorization requirement or may result in a higher cost.  
If you use an out-of-network pharmacy, you may be responsible for any amount over the coinsurance amount. 
Tier 1 Contraceptives covered at No Charge. You may be required to use a lower-cost drug(s). Not all drugs are covered. Pharmacy Deductible does not apply to Tier 1 & 2.

Tier 2 – Your Midrange-Cost Option

Retail: $35 copay

Retail: $35 copay

Not Covered

Tier 3 – Your Highest-Cost Option

Retail: 20% coins after
deductible with
a $100 copay min

Retail: 20% coins after
deductible with
a $100 copay min

Not Covered

Tier 4 – Additional High-Cost Options

Retail: 30% coins after
deductible with
a $200 copay min

Retail: 30% coins after
deductible with
a $200 copay min

Not Covered

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

30% co-ins after deductible

Not Covered

Not Covered

Hospital: $400 outpatient surgery per occurrence. The $400 applies before the annual deductible.

Physician / surgeon fees

30% co-ins after deductible

Not Covered

Not Covered

–––––––––––none–––––––––––

If you need immediate medical attention

Emergency room services

30% co-ins after deductible

30% co-ins after deductible

30% co-ins after deductible

$500 emergency room per occurrence. The $500 applies before the annual deductible.

Emergency medical transportation

30% co-ins after deductible

30% co-ins after deductible

30% co-ins after deductible

–––––––––––none–––––––––––

Urgent care

30% co-ins after deductible

30% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

If you have a hospital stay

Facility fee (e.g., hospital room)

30% co-ins after deductible

Not Covered

Not Covered

–––––––––––none–––––––––––

Physician / surgeon fees

30% co-ins after deductible

Not Covered

Not Covered

–––––––––––none–––––––––––

If you have mental health, behavioral health, or substance abuse needs
 
 

Mental / Behavioral health outpatient services

$30 copay per
visit

$30 copay per
visit

Not Covered

Partial hospitalization/intensive outpatient treatment: 30% co-ins
after deductible

Mental / Behavioral health inpatient services

30% co-ins after deductible

30% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

Substance use disorder outpatient services

$30 copay per
visit

$30 copay per
visit

Not Covered

Partial hospitalization/intensive outpatient treatment: 30% co-ins
after deductible

Substance use disorder inpatient services

30% co-ins after deductible

30% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

If you are pregnant

Prenatal and postnatal care

No Charge 

No Charge

Not Covered 

Additional copays, deductibles, or coinsurance may apply. 

Delivery and all inpatient services

30% co-ins after deductible

30% co-ins after deductible

Not Covered  

–––––––––––none–––––––––––

If you need help recovering or have other special health
needs
 

Home health care

30% co-ins after deductible

30% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

Rehabilitation services

30% co-ins after deductible

30% co-ins after deductible

Not Covered 

Limits per calendar year: physical, speech, occupational – unlimited visits; cardiac – 72 visits; pulmonary – 20 visits.

Habilitative services

30% co-ins after deductible

30% co-ins after deductible

Not Covered

Limits are combined with
Rehabilitation Services above.

Skilled nursing care

30% co-ins after deductible

30% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

Durable medical equipment

30% co-ins after deductible

30% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

Hospice service

30% co-ins after deductible

30% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

If your child needs
dental or eye care
 
 
 
 

Eye exam

30% co-ins after deductible

30% co-ins after deductible

Not Covered

1 exam every 12 months. 

Glasses

30% co-ins after deductible

30% co-ins after deductible

Not Covered

1 pair every 12 months. Cost may increase depending on the frames.

Dental check-up

30% co-ins after deductible

30% co-ins after deductible

Not Covered

Cleanings covered 2 times per 12 months. Limitations may apply.

Important Questions

Answers

Why This Matters:

What is the overall deductible?

Network: $2,000 individual / $4,000 family

Per calendar year. Does not apply to services listed below with copays or "No Charge." 

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No. 

You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

Is there an out-of-pocket limit on my expenses?  

Yes. Network: $6,500 individual / $13,000 family

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services.
This limit helps you plan for health care expenses.

What is not included in the out-of-pocket limit?

Premiums, balance-billed charges and health care this plan doesn’t cover

Even though you pay these expenses, they don’t count toward the out-ofpocket limit.  

Is there an overall annual limit on what the plan pays?

No. 

The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. For a list of network providers, see uhc.com/find–a–physician/xilcompass or call 1-877-512-9940.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.  

Do I need a referral to see a specialist?

Yes. An electronic referral is required to see a Network Specialist 

This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan’s permission before you see the specialist.

Are there services this plan doesn’t cover?

Yes. 

Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services. 

Services You May Need

Your Cost If
You Use a
Network
Provider with a
Referral

Your Cost If
You Use a
Network
Provider without a
Referral

Your Cost If
You Use a
Out-ofNetwork
Provider

Limitations & Exceptions

If you visit a health care provider’s office
or clinic

Primary care visit to treat an injury or illness

$25 copay per visit after deductible

Not Covered

Not Covered

Primary care provider (PCP) must be assigned. No referral required for OB/GYN. Virtual visits
(Telehealth) – $25 copay per visit after deductible by a designated virtual network provider. 

Specialist visit

$50 copay per visit after deductible

Not Covered

Not Covered

Referrals must be from assigned PCP.  

Other practitioner office visit

0% co-ins after deductible

Not Covered

Not Covered

Limited to 16 visits of manipulative (chiropractic) services per year.

Preventive care / screening / immunization

No Charge

Not Covered

Not Covered

Includes preventive health services. 

If you have a test

Diagnostic test (x-ray, blood work)

 Freestanding:
0% co-ins after deductible

 Freestanding:
0% co-ins after deductible

Not Covered

Hospital: 30% co-ins after deductible

Imaging (CT / PET scans, MRIs)

 0% co-ins after deductible

 0% co-ins after deductible

Not Covered

An imaging per occurrence deductible applies before the annual deductible: Freestanding – $350; Hospital – $500

If you need drugs to treat your illness or
condition

More information about prescription drug  coverage is available at
uhc.com/rxfind

Tier 1 – Your Lowest-Cost Option

Retail: $10 copay after deductible

Retail: $10 copay after deductible

Not Covered

Provider means pharmacy for purposes of this section. Retail: Up to a 31 day supply.
Mail-Order: Not Covered You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us.
Certain drugs may have a preauthorization requirement or may result in a higher cost.  
If you use an out-of-network pharmacy, you may be responsible for any amount over the coinsurance amount. 
Tier 1 Contraceptives covered at No Charge. You may be required to use a lower-cost drug(s). Not all drugs are covered. Prescription drug costs are subject to the annual deductible.

Tier 2 – Your Midrange-Cost Option

Retail: $50 copay after deductible

Retail: $50 copay after deductible

Not Covered

Tier 3 – Your Highest-Cost Option

Retail: 20% coins after
deductible with
a $120 copay min

Retail: 20% coins after
deductible with
a $120 copay min

Not Covered

Tier 4 – Additional High-Cost Options

Retail: 30% coins after
deductible with
a $250 copay min

Retail: 30% coins after
deductible with
a $250 copay min

Not Covered

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

 0% co-ins after deductible

 Not Covered

Not Covered

An outpatient surgery per occurrence deductible applies before the annual deductible:
Freestanding – $350; Hospital – $500

Physician / surgeon fees

0% co-ins after deductible

Not Covered

Not Covered

–––––––––––none–––––––––––

If you need immediate medical

Emergency room services

$500 copay per visit after

$500 copay per visit after

$500 copay per visit after

–––––––––––none–––––––––––

attention

deductible

deductible

deductible

Emergency medical transportation

0% co-ins after deductible

0% co-ins after deductible

0% co-ins after deductible

–––––––––––none–––––––––––

Urgent care

0% co-ins after deductible

0% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

If you have a hospital stay

Facility fee (e.g., hospital room)

$1,500 copay per visit after the deductible

Not Covered

Not Covered

–––––––––––none–––––––––––

Physician / surgeon fees

0% co-ins after deductible

Not Covered

Not Covered

–––––––––––none–––––––––––

If you have mental health, behavioral health, or substance abuse needs
 
 

Mental / Behavioral health outpatient services

$25 copay per visit after deductible

$25 copay per visit after deductible

Not Covered

Partial hospitalization/intensive outpatient treatment: 0% co-ins after deductible

Mental / Behavioral health inpatient services

$1,500 copay per visit after the deductible

$1,500 copay per visit after the deductible

Not Covered

–––––––––––none–––––––––––

Substance use disorder outpatient services

$25 copay per visit after deductible

$25 copay per visit after deductible

Not Covered

Partial hospitalization/intensive outpatient treatment: 0% co-ins after deductible

Substance use disorder inpatient services

$1,500 copay per visit after the deductible

$1,500 copay per visit after the deductible

Not Covered

–––––––––––none–––––––––––

If you are pregnant

Prenatal and postnatal care

No Charge 

No Charge

Not Covered 

Additional copays, deductibles, or coinsurance may apply. 

Delivery and all inpatient services

$1,500 copay per visit after the deductible

$1,500 copay per visit after the deductible

Not Covered 

–––––––––––none–––––––––––

If you need help

Home health care

0% co-ins after

0% co-ins after

Not Covered

–––––––––––none–––––––––––

recovering or have other special health
needs
 

deductible

deductible

Rehabilitation services

0% co-ins after deductible

0% co-ins after deductible

Not Covered 

Limits per calendar year: physical, speech, occupational – unlimited visits; cardiac – 72 visits; pulmonary – 20 visits.

Habilitative services

0% co-ins after deductible

0% co-ins after deductible

Not Covered

Limits are combined with
Rehabilitation Services above.

Skilled nursing care

$1,500 copay per visit after the deductible

$1,500 copay per visit after the deductible

Not Covered

–––––––––––none–––––––––––

Durable medical equipment

0% co-ins after deductible

0% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

Hospice service

0% co-ins after deductible

0% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

If your child needs
dental or eye care
 
 
 
 

Eye exam

0% co-ins after deductible

0% co-ins after deductible

Not Covered

1 exam every 12 months. 

Glasses

0% co-ins after deductible

0% co-ins after deductible

Not Covered

1 pair every 12 months. Cost may increase depending on the frames.

Dental check-up

0% co-ins after deductible

0% co-ins after deductible

Not Covered

Cleanings covered 2 times per 12 months. Limitations may apply.

Important Questions

Answers

Why This Matters:

What is the overall deductible?

Network: $3,500 individual / $7,000 family

Per calendar year. Does not apply to services listed below with copays or "No Charge." 

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

Yes, Prescription drugs for tiers 3 and 4 – $1,000 per person. There are no other deductibles.

You must pay all the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

Is there an out-of-pocket limit on my expenses?  

Yes. Network: $6,850 individual / $13,700 family

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services.
This limit helps you plan for health care expenses.

What is not included in the out-of-pocket limit?

Premiums, balance-billed charges and health care this plan doesn’t cover

Even though you pay these expenses, they don’t count toward the out-ofpocket limit.  

Is there an overall annual limit on what the plan pays?

No. 

The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. For a list of network providers, see uhc.com/find–a–physician/xilcompass or call 1-877-512-9940.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.  

Do I need a referral to see a specialist?

Yes. An electronic referral is required to see a Network Specialist 

This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan’s permission before you see the specialist.

Are there services this plan doesn’t cover?

Yes. 

Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services. 

Common 
Medical Event

Services You May Need

Your Cost If
You Use a
Network
Provider with a
Referral

Your Cost If
You Use a
Network
Provider without a
Referral

Your Cost If
You Use a
Out-ofNetwork
Provider

Limitations & Exceptions

If you visit a health care provider’s office
or clinic

Primary care visit to treat an injury or illness

$20 copay per
visit

Not Covered

Not Covered

Primary care provider (PCP) must be assigned. No referral required for
OB/GYN. Virtual visits
(Telehealth) – $20 copay per visit by a designated virtual network provider. 

Specialist visit

$60 copay per visit  

Not Covered

Not Covered

Referrals must be from assigned PCP.  

Other practitioner office visit

20% co-ins after deductible

Not Covered

Not Covered

Limited to 16 visits of manipulative (chiropractic) services per year.

Preventive care / screening / immunization

No Charge

Not Covered

Not Covered

Includes preventive health services. 

If you have a test

Diagnostic test (x-ray, blood work)

 Freestanding:
20% co-ins after deductible

 Freestanding:
20% co-ins after deductible

Not Covered

Hospital: 40% co-ins after deductible

Imaging (CT / PET scans, MRIs)

 20% co-ins after deductible

20% co-ins after deductible

Not Covered

Hospital: $400 imaging per occurrence. The $400 applies before the annual deductible.

If you need drugs to

Tier 1 – Your Lowest-Cost

Retail: $5 copay

Retail: $5 copay

Not Covered

Provider means pharmacy for

treat your illness or
condition

More information about prescription drug  coverage is available at
uhc.com/rxfind  

Option

purposes of this section. Retail: Up to a 31 day supply.
Mail-Order: Not Covered You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us.
Certain drugs may have a preauthorization requirement or may result in a higher cost.  
If you use an out-of-network pharmacy, you may be responsible for any amount over the coinsurance amount. 
Tier 1 Contraceptives covered at No Charge. You may be required to use a lower-cost drug(s). Not all drugs are covered. Pharmacy Deductible does not apply to Tier 1 & 2.

Tier 2 – Your Midrange-Cost Option

Retail: $40 copay

Retail: $40 copay

Not Covered

Tier 3 – Your Highest-Cost Option

Retail: 20% coins after
deductible with
a $100 copay min

Retail: 20% coins after
deductible with
a $100 copay min

Not Covered

Tier 4 – Additional High-Cost Options

Retail: 30% coins after
deductible with
a $200 copay min

Retail: 30% coins after
deductible with
a $200 copay min

Not Covered

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

20% co-ins after deductible

Not Covered

Not Covered

Hospital: $400 outpatient surgery per occurrence. The $400 applies before the annual deductible.

Physician / surgeon fees

20% co-ins after deductible

Not Covered

Not Covered

–––––––––––none–––––––––––

If you need immediate medical attention

Emergency room services

20% co-ins after deductible

20% co-ins after deductible

20% co-ins after deductible

$500 emergency room per occurrence. The $500 applies before the annual deductible.

Emergency medical transportation

20% co-ins after deductible

20% co-ins after deductible

20% co-ins after deductible

–––––––––––none–––––––––––

Urgent care

20% co-ins after deductible

20% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

If you have a hospital stay

Facility fee (e.g., hospital room)

20% co-ins after deductible

Not Covered

Not Covered

–––––––––––none–––––––––––

Physician / surgeon fees

20% co-ins after deductible

Not Covered

Not Covered

–––––––––––none–––––––––––

If you have mental health, behavioral health, or substance abuse needs
 
 

Mental / Behavioral health outpatient services

$20 copay per
visit

$20 copay per
visit

Not Covered

Partial hospitalization/intensive outpatient treatment: 20% co-ins
after deductible

Mental / Behavioral health inpatient services

20% co-ins after deductible

20% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

Substance use disorder outpatient services

$20 copay per
visit

$20 copay per
visit

Not Covered

Partial hospitalization/intensive outpatient treatment: 20% co-ins
after deductible

Substance use disorder inpatient services

20% co-ins after deductible

20% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

If you are pregnant

Prenatal and postnatal care

No Charge 

No Charge

Not Covered 

Additional copays, deductibles, or coinsurance may apply. 

Delivery and all inpatient services

20% co-ins after deductible

20% co-ins after deductible

Not Covered 

–––––––––––none–––––––––––

If you need help recovering or have other special health
needs
 

Home health care

20% co-ins after deductible

20% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

Rehabilitation services

20% co-ins after deductible

20% co-ins after deductible

Not Covered 

Limits per calendar year: physical, speech, occupational – unlimited visits; cardiac – 72 visits; pulmonary – 20 visits.

Habilitative services

20% co-ins after deductible

20% co-ins after deductible

Not Covered

Limits are combined with
Rehabilitation Services above.

Skilled nursing care

20% co-ins after deductible

20% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

Durable medical equipment

20% co-ins after deductible

20% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

Hospice service

20% co-ins after deductible

20% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

If your child needs
dental or eye care
 
 
 
 

Eye exam

20% co-ins after deductible

20% co-ins after deductible

Not Covered

1 exam every 12 months. 

Glasses

20% co-ins after deductible

20% co-ins after deductible

Not Covered

1 pair every 12 months. Cost may increase depending on the frames.

Dental check-up

20% co-ins after deductible

20% co-ins after deductible

Not Covered

Cleanings covered 2 times per 12 months. Limitations may apply.

Important Questions

Answers

Why This Matters:

What is the overall deductible?

Network: $4,500 individual / $9,000 family

Per calendar year. Does not apply to services listed below with copays or "No Charge." 

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

Yes, Prescription drugs for tiers 3 and 4 – $1,000 per person. There are no other deductibles.

You must pay all the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

Is there an out-of-pocket limit on my expenses?  

Yes. Network: $6,850 individual / $13,700 family

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services.
This limit helps you plan for health care expenses.

What is not included in the out-of-pocket limit?

Premiums, balance-billed charges and health care this plan doesn’t cover

Even though you pay these expenses, they don’t count toward the out-ofpocket limit.  

Is there an overall annual limit on what the plan pays?

No. 

The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. For a list of network providers, see uhc.com/find–a–physician/xilcompass or call 1-877-512-9940.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.  

Do I need a referral to see a specialist?

Yes. An electronic referral is required to see a Network Specialist 

This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan’s permission before you see the specialist.

Are there services this plan doesn’t cover?

Yes. 

Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services. 

Services You May Need

Your Cost If
You Use a
Network
Provider with a
Referral

Your Cost If
You Use a
Network
Provider without a
Referral

Your Cost If
You Use a
Out-ofNetwork
Provider

Limitations & Exceptions

If you visit a health care provider’s office
or clinic

Primary care visit to treat an injury or illness

$10 copay per
visit

Not Covered

Not Covered

Primary care provider (PCP) must be assigned. No referral required for
OB/GYN. Virtual visits
(Telehealth) – $10 copay per visit by a designated virtual network provider. 

Specialist visit

$30 copay per visit  

Not Covered

Not Covered

Referrals must be from assigned PCP.  

Other practitioner office visit

0% co-ins after deductible

Not Covered

Not Covered

Limited to 16 visits of manipulative (chiropractic) services per year.

Preventive care / screening / immunization

No Charge

Not Covered

Not Covered

Includes preventive health services. 

If you have a test

Diagnostic test (x-ray, blood work)

 Freestanding:
0% co-ins after deductible

 Freestanding:
0% co-ins after deductible

Not Covered

Hospital: 20% co-ins after deductible

Imaging (CT / PET scans, MRIs)

 0% co-ins after deductible

0% co-ins after deductible

Not Covered

Hospital: $400 imaging per occurrence. The $400 applies before the annual deductible.

If you need drugs to

Tier 1 – Your Lowest-Cost

Retail: $5 copay

Retail: $5 copay

Not Covered

Provider means pharmacy for

treat your illness or
condition

More information about prescription drug  coverage is available at
uhc.com/rxfind  

Option

purposes of this section. Retail: Up to a 31 day supply.
Mail-Order: Not Covered You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us.
Certain drugs may have a preauthorization requirement or may result in a higher cost.  
If you use an out-of-network pharmacy, you may be responsible for any amount over the coinsurance amount. 
Tier 1 Contraceptives covered at No Charge. You may be required to use a lower-cost drug(s). Not all drugs are covered. Pharmacy Deductible does not apply to Tier 1 & 2.

Tier 2 – Your Midrange-Cost Option

Retail: $40 copay

Retail: $40 copay

Not Covered

Tier 3 – Your Highest-Cost Option

Retail: 20% coins after
deductible with
a $120 copay min

Retail: 20% coins after
deductible with
a $100 copay min

Not Covered

Tier 4 – Additional High-Cost Options

Retail: 30% coins after
deductible with
a $250 copay min

Retail: 30% coins after
deductible with
a $200 copay min

Not Covered

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

0% co-ins after deductible

Not Covered

Not Covered

Hospital: $400 outpatient surgery per occurrence. The $400 applies before the annual deductible.

Physician / surgeon fees

0% co-ins after deductible

Not Covered

Not Covered

–––––––––––none–––––––––––

If you need immediate medical attention

Emergency room services

0% co-ins after deductible

0% co-ins after deductible

0% co-ins after deductible

$500 emergency room per occurrence. The $500 applies before the annual deductible.

Emergency medical transportation

0% co-ins after deductible

0% co-ins after deductible

0% co-ins after deductible

–––––––––––none–––––––––––

Urgent care

0% co-ins after deductible

0% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

If you have a hospital stay

Facility fee (e.g., hospital room)

0% co-ins after deductible

Not Covered

Not Covered

–––––––––––none–––––––––––

Physician / surgeon fees

0% co-ins after deductible

Not Covered

Not Covered

–––––––––––none–––––––––––

If you have mental health, behavioral health, or substance abuse needs
 
 

Mental / Behavioral health outpatient services

$10 copay per
visit

$10 copay per
visit

Not Covered

Partial hospitalization/intensive outpatient treatment: 0% co-ins after deductible

Mental / Behavioral health inpatient services

0% co-ins after deductible

0% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

Substance use disorder outpatient services

$10 copay per
visit

$10 copay per
visit

Not Covered

Partial hospitalization/intensive outpatient treatment: 0% co-ins after deductible

Substance use disorder inpatient services

0% co-ins after deductible

0% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

If you are pregnant

Prenatal and postnatal care

No Charge 

No Charge

Not Covered 

Additional copays, deductibles, or coinsurance may apply. 

Delivery and all inpatient services

0% co-ins after deductible

0% co-ins after deductible

Not Covered 

–––––––––––none–––––––––––

If you need help recovering or have other special health
needs
 

Home health care

0% co-ins after deductible

0% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

Rehabilitation services

0% co-ins after deductible

0% co-ins after deductible

Not Covered 

Limits per calendar year: physical, speech, occupational – unlimited visits; cardiac – 72 visits; pulmonary – 20 visits.

Habilitative services

0% co-ins after deductible

0% co-ins after deductible

Not Covered

Limits are combined with
Rehabilitation Services above.

Skilled nursing care

0% co-ins after deductible

0% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

Durable medical equipment

0% co-ins after deductible

0% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

Hospice service

0% co-ins after deductible

0% co-ins after deductible

Not Covered

–––––––––––none–––––––––––

If your child needs
dental or eye care
 
 
 
 

Eye exam

0% co-ins after deductible

0% co-ins after deductible

Not Covered

1 exam every 12 months. 

Glasses

0% co-ins after deductible

0% co-ins after deductible

Not Covered

1 pair every 12 months. Cost may increase depending on the frames.

Dental check-up

0% co-ins after deductible

0% co-ins after deductible

Not Covered

Cleanings covered 2 times per 12 months. Limitations may apply.