Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 4413 Outpatient Hospital/ Facility–Diagnostic Services, Pre-admission testing Outpatient Professional Services Labs and X-Ray Surgery Maternity Benefits Hospitalization Birthing Center Professional— Pre & Postnatal Care Newborn Pediatric Inpatient Care Infertility Services Infertility Counseling and Testing Artificial Insemination In Vitro Fertilization Mental Health & Substance Abuse Benefits-Inpatient Professional Mental Health & Substance Abuse Benefits-Outpatient Professional Emergency & Urgent Care—In Area In Office Urgent Care Center Plan Affiliated Emergency Room Ambulance – Ground and Air Plan Benefits Covered at 100%. Diagnostic Lab and X-Ray covered at 100%. Profes- sional services covered at 100%. Outpatient hospital covered at 100%. Professional services covered at 100%. Covered at 100%. Covered at 100%. Covered at 100% after the first visit to applicable PCP. Nursery care covered at 100%. Covered at 100%. Covered at 100% after applicable PCP or specialist copay; limit of 3 attempts per live birth; not to exceed lifetime limit $100,000. Covered at 100%. Covered at 100% after $20 copay. Covered at 100% after $25 copay. $150 copay for ER; waived if admitted. Covered at 100% for emergencies and some non-emergency situations. UnitedHealthcare Choice Plus POS In-Network Covered at 100%. Diagnostic Lab and X-Ray covered at 100%. Profes- sional services covered at 100%. Outpatient hospital covered at 100%. Professional services covered at 100%. Covered at 100%. Covered at 100%. Covered at 100% after the first visit to applicable PCP. Nursery care covered at 100%. Covered at 100% after 50% coinsurance. 50% coinsurance, limit of 3 attempts per live birth; not to exceed lifetime limit $100,000. Covered at 100%. Covered at 100% after $20 copay. Covered at 100% after $20 copay. $150 copay for ER; waived if admitted. Covered at 100% for emergencies and some non-emergency situations. UnitedHealthcare Select EPO In-Network Only Covered at 100%. Covered at 100%. (Outpatient Specialty Imaging $50 copay) $25 copay. Covered at 100%. Covered at 100% if Kaiser authorized. $25 copay for initial visit, then covered at 100%. Covered at 100%. 50% of allowable charges. 50% of allowable charges for up to 3 attempts per live birth. Not to exceed lifetime limit of $100,000. Covered at 100%. Copays: $20 Individual and $10 group therapy. $25 copay. $150 copay for emergency room; waived if admitted. $50 copay. Kaiser Permanente HMO In-Network Only 2017 Medical Summary of Services This is a summary of health care benefits. In the event of a difference between this summary and the plan brochure, the plan brochure will govern. PLEASE NOTE: Copay (copayment) charges are PER VISIT unless specified otherwise. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible; Limit of 3 attempts per live birth; not to exceed lifetime limit $100,000. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 100% after $20 copay. Covered at the network level. Covered at 100% for emergencies and some non-emergency situations. UnitedHealthcare Choice Plus POS Out-of-Network