Small Business Health Options Program Guide 2024
|
Congressional Plan Options
|
Washington, D.C.
Your guide to understanding
your 2024 plan options
Plans available to members of Congress,
staff and dependents
1
1
How to choose health
care coverage
Narrow down your plan options
To help narrow down plan options, consider what is most important to you and your dependents.
Choice Plus Insurance Plans
Broad, national access to physicians and hospitals, out-of-network coverage and no referrals needed to
see a specialist.
Choice Insurance Plans
Broad, national access to physicians and hospitals, network-only coverage and no referrals needed to see
a specialist.
Optimum Choice, Inc. (OCI) HMO Plans
Local access only to physician and hospitals, network-only coverage and a primary care physician (PCP)
to coordinate care and refer specialist services.
Core Essential Plans
Tailored local access only to physicians and hospitals, network-only coverage and no referrals needed to
see a specialist.
UnitedHealthcare Navigate® HMO Plans
Tailored local access only to physicians and hospitals, network-only coverage and a primary care
physician (PCP) to coordinate care and refer specialist services.
Choose plan features
With many plans to choose from, you have the control to pick the deductible, health savings account
(HSA) compatibility and cost-share levels that are right for you. Coverage also includes:
UnitedHealthcare Rewards is available on all of our plans. You can earn dollars for completing certain
healthy actions like tracking your daily steps, active minutes and sleep, and by completing one-time
reward activities like biometric screenings.
Care Cash® is a program that puts cash in members’ hands. Just by signing up for the plan, you get a
pre-paid debit card of $200 (individuals) or $500 (families) to help pay toward cost sharing for certain
eligible network health care expenses. Care Cash is available on all non-HSA and non-HRA plans.
$0 Kid’s Copay is a plan feature available on all non-HSA and non-HRA plans. With this feature, there is
no copay for network primary care office visits for children under 19.
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How to choose health care coverage
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Additional considerations
Essential coverage in every plan
These plans cover 10 essential benefits, preventive care services
like annual wellness exams and flu vaccinations, and pre-existing
conditions, and they include prescriptions and lab services.
Easy access to care
Access to doctors, clinics and hospitals with all of our health
plans. If you have a question or need advice, you can call
the toll-free number on your health plan ID card to talk with
registered nurses 24/7.
24/7 Virtual Visits
Access to Behavioral and Medical health care providers from
a computer, mobile device* and over the telephone. Simply
log in to myuhc.com®, select a participating 24/7 Virtual Visits
provider, and out-of-pocket costs will be $0 when covered by
both HSA and non-HSA plans.
Tools to manage health and costs
Through online resources, mobile apps and myuhc.com, you
have access to:
• Apps, tools and programs
to manage your health
• Estimated health care costs
• Health care provider search
• 24/7 access to
benefit information
UnitedHealth Premium Program
The UnitedHealth Premium® program can help you find doctors who are right for you and your family.
Find quality, cost-efficient care. For over 15 years, physicians in the UnitedHealth Premium® program have been measured
against criteria for providing quality and cost-efficient care. The Premium designation makes it easy for you to find doctors
who meet national standards for quality and local market benchmarks for cost efficiency. The UnitedHealth Premium program
evaluates physicians in various specialties using evidence-based medicine and national standardized measures to help you
locate quality and cost-efficient doctors. It’s easy to find a UnitedHealth Premium Care Physician. Just go to myuhc.com
Find a Provider. Choose smart. Look for blue hearts.
>
Premium Care Physician
The physician meets the
UnitedHealth Premium
program quality and cost-
efficient care criteria.
Quality Care Physician
This physician meets the
UnitedHealth Premium
program quality care
criteria but does not meet
the program’s criteria for
cost-efficient care.
Does Not Meet Premium
Quality Criteria
The physician does not meet
the UnitedHealth Premium
program quality criteria, so
the physician is not eligible
for a Premium designation.
Not Evaluated for Premium Care
The physician’s specialty is not
evaluated in the UnitedHealth
Premium program, the physician
does not have enough claims
data for program evaluation or the
physician’s program evaluation is
in process.
*Data rates may apply.
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How to choose health care coverage
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UnitedHealth Premium Program specialties
Allergy
• Allergy
• Allergy and immunology
Cardiology
•
Cardiac diagnostic
• Cardiology
• Cardiovascular disease
• Clinical cardiac
electrophysiology
• Interventional cardiology
Ear, nose and throat
•
Head and neck surgery
• Laryngology
• Otolaryngology
• Otology
• Pediatric otolaryngology
• Rhinology
Endocrinology
• Endocrinology, diabetes
and metabolism
Family medicine
•
Family practice
• General practice
• Preventive medicine
Gastroenterology
•
Digestive diseases
• Gastroenterology
• Hepatology — liver disease
General surgery
•
Abdominal surgery
• Colon and rectal surgery
• Proctology
• Surgery
Int
ernal medicine
• Geriatric medicine
• Internal medicine
• Pediatric internal medicine
Nephrology
•
Nephrology
Neurology
•
Neurology
• Neurology and psychiatry
• Neuromuscular disease
Neurosurgery, orthopedics
and spine
•
Back and spine surgery
• Hand surgery
• Knee surgery
• Neurology surgery
• Orthopedic surgery
• Shoulder surgery
• Sports medicine
Ob
stetrics and gynecology
• Gynecology
• Obstetrics
• Obstetrics and gynecology
Pediatrics
•
Adolescent medicine
• Pediatric adolescent
• Pediatrics
Pulmonology
•
Pulmonary medicine
Rheumatology
•
Rheumatology
Urology
•
Urology
Designated Diagnostic Providers
Designated Diagnostic Providers (DDP) are laboratory and imaging service
providers that meet certain quality and efficiency requirements. With your DDP
benefit, you’ll have the highest level of coverage — and likely save money — when
you use a DDP for outpatient lab and imaging services. If you don’t use a DDP,
your services may receive a lower level of coverage and you may be responsible
for a higher out-of-pocket cost.
Just look for the green check mark
To find a lower-cost DDP near you, go to myuhc.com > Find Care & Costs
Medical Directory Places.
>
>
Choose whether you’d like lab or imaging services and then look for the green
check
0
to confirm DDP status.
ABC
Laboratory
Laboratory
1234
Any
Street
Any City, State 12345
(123) 456-7890
PHONE
5.9 Miles Aw
ay
Get Directions I [!!
0 Designated Diagnostic Provider
DDP outpatient lab
and imaging services
Using a DDP may help you
save money on many
services, including:
Lab services
• Blood draws
• Blood glucose tests
• Metabolic tests/panels
• Rapid strep tests
Imaging services
• CT and PET scans
• MRI/MRAs
• Nuclear medicine scans
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How to choose health care coverage
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Why choose a health plan with a health savings account (HSA)?
Your premium costs may be lower
• You will have a higher deductible but usually pay less in
plan premiums
• This can add up to big savings, depending on your usage
You own the HSA
The HSA is a personal bank account, which means:
• There is no “use-it-or-lose-it” rule
• If you leave your employer or change plans, you can take
your HSA with you
The HSA helps you pay less in taxes*
You won’t have to pay federal income tax on:
• Deposits you or others make to your HSA
• Money you spend from your HSA on qualified expenses
• Interest earned on the HSA
Use the HSA for medical and pharmacy expenses, and more
When you have qualifying medical expenses, like a doctor visit or prescription, you can pay for them using
the money in your HSA. Or, you can save the money for a future medical need — even into retirement. It’s
your choice. Plus, you can use the money for expenses not covered by your plan such as dental and vision.
How a plan with HSA works
Eligible preventive care received in the network is covered 100%, and you won’t have any out-of-pocket costs.
Your deductible — You pay out-of-pocket until you reach the deductible. When you have an eligible
expense, such as a doctor visit, the entire cost of the visit will apply to your deductible. You will pay the full
cost of your health care expenses until you meet your deductible. You can choose to pay for care from your
HSA or you can choose to pay another way (i.e., cash, credit card) and let your HSA grow. It’s your money.
It’s your choice.
Your coverage — Your plan pays a percentage of your expenses. Once the deductible is paid, your health
plan may have cost-share. With cost-share, the plan shares the cost of expenses with you. The plan will pay a
percentage of each eligible expense, and you will pay the rest. For example, if your plan pays 80% of the cost,
you will be responsible for paying the remaining 20%. After the deductible, your plan may have a copayment
for certain services, such as prescriptions.
Your out-of-pocket limit — The out-of-pocket limit is the most you will have to pay in the plan year for
covered services. The plan will then pay 100% of all remaining covered expenses for the rest of the plan
year. Your deductible, coinsurance and even copayments will apply to your out-of-pocket limit.
If you have questions about Health Savings Accounts available through UnitedHealthcare plans, please call
Optum Bank HSA at 800-791-9361 or send an email to HSA[email protected].
* Subject to limits. Consult a tax advisor.
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How to choose health care coverage
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Behavioral health resources
UnitedHealthcare benefits include resources that offer support for many issues and concerns. Consider these behavioral
health resources when you or your family members need support.
AbleTo
®
(Telephonic/Video outreach)
AbleTo focuses on individuals with unmet
behavioral health needs coupled with chronic
medical conditions and/or major life events. This
evidence-based, structured therapy program helps
to strengthen medical recovery and self-care.
AbleTo provides virtual support for depression,
anxiety and stress that may accompany health
issues, such as cardiac conditions, diabetes,
chronic pain and cancer. Individuals who may
not take advantage of treatment on their own
are identified and contacted proactively. AbleTo
engages members in both behavioral coaching
and personalized therapy via phone or video twice
a week for up to 8 weeks.
Behavioral health in-person visits
Behavioral health care is a service for individuals
with specific diagnoses such as clinical
depression, bipolar disorder, etc. Substance use
disorder treatment benefits also fall under this
category. Behavioral health care, typically, is longer
term in nature.
The behavioral health benefit can help with
ongoing stressful situations, such as:
• Clinical depression
• Bipolar disorder
• Alcohol or drug
use disorders
• Domestic violence
• Eating disorders
• Compulsive disorders
• Medication
management
Behavioral health virtual visits: myuhc.com
Behavioral health care from the comfort of home
is now more accessible to help you and your
dependents stay healthier and more productive.
With UnitedHealthcare, members have access to
behavioral health providers, including sessions with
licensed psychiatrists, through our video-based
technology on our member website, myuhc.com.
Live and work well: liveandworkwell.com
Dedicated member portal with many resources and
online Cognitive Behavioral Therapy (CBT)
1
tools.
Members can connect via myuhc.com or access
directly using their HealthSafe ID
®
.
Psych Hub videos: liveandworkwell.com
(under Popular Tools section)
Educational video resources for understanding
behavioral health topics. With shame and stigma
often being reasons for non-treatment,
2
the Psych
Hub videos are meant to help educate members
on a variety of behavioral health topics, as well as
increase their understanding of care options and
support overall awareness.
Recovery Record
(available through the App Store®)
This app helps to promote recommended
treatment options to help engage and improve
outcomes for members with eating disorders.
Recovery Record provides members and providers
with a way to connect on provider-recommended
treatment plans and progress in between regularly
scheduled appointments to help improve member
engagement and outcomes.
Substance Use Disorder helpline and website:
855-780-5995 / liveandworkwell.com
Specialized substance use recovery advocates
are available by phone or online to help navigate
recovery options.
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Compare plans
Choice Plus insurance plans
UnitedHealthcare Insurance Company
Choice Plus offers broad, national access to physicians, hospitals and
out-of-network coverage, and there are no referrals needed to see a specialist.
How does it work?
You have the choice to see any doctor or specialist without a referral, in or out
of the network. Although the insurance coverage will pay for out-of-network
services, it’s important to know that you save money when you use the network.
The Choice Plus Network
National access to over 1,713,250 physicians and health care professionals,
7,030 hospitals and 67,000 pharmacies.*
Members can
receive services
outside the
network, if they
choose, without
a referral.
* Network counts based on internal network analysis as of Q3 2023.
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1 2 3
Choice Plus insurance plans
Plan Name
UnitedHealthcare Choice Plus Gold
0-2 500 750-2 1000 1500-1 1500-2 1500-3 1500-4
HSA
Plan Code DG-RP DI-AL DG-RC DG-RU DG-RH DG-Q5 DG-RF DG-QZ
Network
Individual
Deductible
$0 $500 $750 $1,000 $1,500 $1,500 $1,500 $1,500
Network
Family
Deductible
$0 $1,000 $1,500 $2,000 $3,000 $3,000 $3,000 $3,000
Network
Coinsurance
0% 20% 20% 0% 0% 20% 20% 20%
Network
Individual
Out-of-Pocket
Limit
$9,450 $5,800 $9,000 $7,500 $8,550 $8,550 $5,800 $8,550
Network Family
Out-of-Pocket
Limit
$18,900 $11,600 $18,000 $15,000 $17,100 $17,100 $11,600 $17,100
24/7 Virtual Visits $0 $0 $0 $0 $0 $0 $0 $0
PCP Office
Visit
$30 $25 $30 $20 $35 $0 $30 $10
Specialist
Office Visit
$60 $50
$60 (PD) $65
(non-PD)
$40 $70
$60 (PD) $120
(non-PD)
$60
$40 (PD) $80
(non-PD)
Urgent Care $60 $60 $60 $60 $60 $25 $60 $25
Emergency Room $500 $300
$400 after
deductible
$300 after
deductible
$350 after
deductible
$350 after
deductible
$350 after
deductible
40% after
deductible
Pharmacy
Pharmacy Code N09S N44 N09S K08S K08S K05S K08S K43S
Pharmacy
Deductible Type
$0 $0 $0
$250
Tier 2,3,4
$250
Tier 2,3,4
$250
Tier 2,3,4
$250
Tier 2,3,4
Combined
Tier 1 $15 $15 $15 $10 $10 $5 $10 $10
Tier 2 $40 $50 $40 $40 $40 $50 $40 $40
Tier 2 Specialty $40 N/A $40 $40 $40 $50 $40 $40
Tier 3 $75 $70 $75 $75 $75 $80 $75 $75
Tier 3 Specialty $100 N/A $100 $100 $100 $100 $100 $100
Tier 4 $125 $150 $125 $125 $125 $125 $125 $125
Tier 4 Specialty $150 N/A $150 $150 $150 $150 $150 $150
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Choice Plus insurance plans
Plan Name
UnitedHealthcare Choice Plus Gold
HSA
HSA 1800 2000 2500-1 HSA 2500-1 3000
HSA HSA
Plan Code DG-QL DG-RA DG-Q2 DG-QQ DG-Q3
Network
Individual
Deductible
$1,800 $2,000 $2,500 $2,500 $3,000
Network
Family Deductible
$3,600 $4,000 $5,000 $5,000 $6,000
Network
Coinsurance
10% 0% 20% 10% 0%
Network
Individual Out-of-
Pocket Limit
$4,400 $7,000 $8,550 $4,350 $8,550
Network Family
Out-of-Pocket Limit
$8,800 $14,000 $17,100 $8,700 $17,100
24/7 Virtual Visits $0 $0 $0 $0 $0
PCP Office Visit 10% after deductible $30 $10 10% after deductible $0
Specialist Office
Visit
10% after deductible $60 after deductible $40 (PD) $80 (non-PD) 10% after deductible $50 (PD) $100 (non-PD)
Urgent Care 10% after deductible $60 $25 10% after deductible $25
Emergency Room 10% after deductible $350 after deductible 40% after deductible 10% after deductible $350 after deductible
Pharmacy
Pharmacy Code N09S K08S K43S K43S K05S
Pharmacy
Deductible Type
$0
$250
Tier 2,3,4
Combined Combined
$250
Tier 2,3,4
Tier 1 $15 $10 $10 $10 $5
Tier 2 $40 $40 $40 $40 $50
Tier 2 Specialty $40 $40 $40 $40 $50
Tier 3 $75 $75 $75 $75 $80
Tier 3 Specialty $100 $100 $100 $100 $100
Tier 4 $125 $125 $125 $125 $125
Tier 4 Specialty $150 $150 $150 $150 $150
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1 2 3
Choice Plus insurance rates
Rates displayed are full monthly premium rates based on a single policyholder.
Plan Name
UnitedHealthcare Choice Plus Gold
0-2 500 750-2 1000 1500-1 1500-2 1500-3 1500-4
Plan Code DG-RP DI-AL DG-RC DG-RU DG-RH DG-Q5 DG-RF DG-QZ
Age
0-14 $415.94 $413.46 $383.13 $413.51 $397.08 $379.04 $379.24 $366.53
15 $415.94 $413.46 $383.13 $413.51 $397.08 $379.04 $379.24 $366.53
16 $415.94 $413.46 $383.13 $413.51 $397.08 $379.04 $379.24 $366.53
17 $415.94 $413.46 $383.13 $413.51 $397.08 $379.04 $379.24 $366.53
18 $415.94 $413.46 $383.13 $413.51 $397.08 $379.04 $379.24 $366.53
19 $415.94 $413.46 $383.13 $413.51 $397.08 $379.04 $379.24 $366.53
20 $415.94 $413.46 $383.13 $413.51 $397.08 $379.04 $379.24 $366.53
21 $462.38 $459.62 $425.91 $459.68 $441.41 $421.36 $421.58 $407.45
22 $462.37 $459.61 $425.90 $459.67 $441.40 $421.35 $421.57 $407.44
23 $462.37 $459.61 $425.90 $459.67 $441.40 $421.35 $421.57 $407.44
24 $462.37 $459.61 $425.90 $459.67 $441.40 $421.35 $421.57 $407.44
25 $462.37 $459.61 $425.90 $459.67 $441.40 $421.35 $421.57 $407.44
26 $462.37 $459.61 $425.90 $459.67 $441.40 $421.35 $421.57 $407.44
27 $462.37 $459.61 $425.90 $459.67 $441.40 $421.35 $421.57 $407.44
28 $473.18 $470.36 $435.86 $470.42 $451.72 $431.20 $431.43 $416.97
29 $483.36 $480.47 $445.23 $480.53 $461.43 $440.47 $440.71 $425.93
30 $495.44 $492.48 $456.36 $492.55 $472.97 $451.49 $451.73 $436.58
31 $508.16 $505.13 $468.08 $505.19 $485.11 $463.08 $463.32 $447.79
32 $519.61 $516.51 $478.62 $516.57 $496.04 $473.51 $473.76 $457.88
33 $531.70 $528.52 $489.75 $528.59 $507.58 $484.52 $484.78 $468.53
34 $544.42 $541.16 $501.47 $541.23 $519.72 $496.11 $496.38 $479.74
35 $557.14 $553.81 $513.19 $553.88 $531.86 $507.70 $507.97 $490.95
36 $569.86 $566.45 $524.90 $566.52 $544.01 $519.29 $519.57 $502.15
37 $582.58 $579.10 $536.62 $579.17 $556.15 $530.89 $531.17 $513.36
38 $589.57 $586.05 $543.06 $586.12 $562.83 $537.26 $537.55 $519.53
39 $596.57 $593.00 $549.51 $593.08 $569.51 $543.64 $543.93 $525.69
40 $620.10 $616.40 $571.18 $616.47 $591.97 $565.08 $565.38 $546.43
41 $644.27 $640.42 $593.45 $640.50 $615.04 $587.10 $587.42 $567.73
42 $669.71 $665.71 $616.88 $665.79 $639.33 $610.29 $610.61 $590.14
43 $695.78 $691.63 $640.90 $691.71 $664.22 $634.05 $634.39 $613.12
44 $723.13 $718.81 $666.09 $718.90 $690.33 $658.97 $659.32 $637.22
45 $751.12 $746.63 $691.87 $746.72 $717.04 $684.47 $684.84 $661.88
(continued)
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1 2 3
Choice Plus insurance rates
Rates displayed are full monthly premium rates based on a single policyholder.
(continued)
Plan Name
UnitedHealthcare Choice Plus Gold
HSA 1800 2000 2500-1 HSA 2500-1 3000
Plan Code DG-QL DG-RA DG-Q2 DG-QQ DG-Q3
Age
0-14 $401.87 $373.90 $357.40 $378.37 $383.62
15 $401.87 $373.90 $357.40 $378.37 $383.62
16 $401.87 $373.90 $357.40 $378.37 $383.62
17 $401.87 $373.90 $357.40 $378.37 $383.62
18 $401.87 $373.90 $357.40 $378.37 $383.62
19 $401.87 $373.90 $357.40 $378.37 $383.62
20 $401.87 $373.90 $357.40 $378.37 $383.62
21 $446.74 $415.64 $397.31 $420.62 $426.45
22 $446.73 $415.63 $397.30 $420.61 $426.44
23 $446.73 $415.63 $397.30 $420.61 $426.44
24 $446.73 $415.63 $397.30 $420.61 $426.44
25 $446.73 $415.63 $397.30 $420.61 $426.44
26 $446.73 $415.63 $397.30 $420.61 $426.44
27 $446.73 $415.63 $397.30 $420.61 $426.44
28 $457.17 $425.35 $406.59 $430.44 $436.42
29 $467.00 $434.50 $415.33 $439.70 $445.80
30 $478.68 $445.36 $425.72 $450.69 $456.95
31 $490.97 $456.80 $436.65 $462.26 $468.68
32 $502.03 $467.09 $446.48 $472.68 $479.24
33 $513.71 $477.95 $456.87 $483.67 $490.38
34 $525.99 $489.38 $467.80 $495.24 $502.11
35 $538.28 $500.82 $478.73 $506.81 $513.84
36 $550.57 $512.25 $489.66 $518.38 $525.58
37 $562.86 $523.69 $500.58 $529.95 $537.31
38 $569.62 $529.98 $506.60 $536.32 $543.76
39 $576.38 $536.26 $512.61 $542.68 $550.21
40 $599.12 $557.42 $532.83 $564.09 $571.92
41 $622.47 $579.14 $553.59 $586.07 $594.21
42 $647.05 $602.01 $575.45 $609.21 $617.67
43 $672.24 $625.45 $597.86 $632.93 $641.72
44 $698.66 $650.03 $621.36 $657.81 $666.94
45 $725.70 $675.19 $645.40 $683.27 $692.75
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1 2 3
Choice Plus insurance rates
Rates displayed are full monthly premium rates based on a single policyholder.
Plan Name
UnitedHealthcare Choice Plus Gold
0-2 500 750-2 1000 1500-1 1500-2 1500-3 1500-4
Plan Code DG-RP DI-AL DG-RC DG-RU DG-RH DG-Q5 DG-RF DG-QZ
Age
46 $780.37 $775.71 $718.81 $775.81 $744.97 $711.13 $711.51 $687.66
47 $810.90 $806.06 $746.93 $806.16 $774.12 $738.95 $739.35 $714.56
48 $842.70 $837.67 $776.22 $837.77 $804.47 $767.93 $768.34 $742.58
49 $875.77 $870.54 $806.69 $870.65 $836.05 $798.07 $798.49 $771.73
50 $910.12 $904.68 $838.32 $904.79 $868.83 $829.36 $829.81 $801.99
51 $945.73 $940.08 $871.13 $940.20 $902.83 $861.82 $862.28 $833.37
52 $982.62 $976.75 $905.11 $976.87 $938.05 $895.44 $895.91 $865.88
53 $1,020.78 $1,014.68 $940.26 $1,014.81 $974.48 $930.21 $930.71 $899.51
54 $1,060.85 $1,054.51 $977.16 $1,054.64 $1,012.73 $966.72 $967.24 $934.81
55 $1,102.19 $1,095.60 $1,015.24 $1,095.74 $1,052.19 $1,004.39 $1,004.93 $971.24
56 $1,145.44 $1,138.59 $1,055.08 $1,138.74 $1,093.48 $1,043.81 $1,044.36 $1,009.35
57 $1,189.96 $1,182.85 $1,096.09 $1,183.00 $1,135.98 $1,084.38 $1,084.96 $1,048.58
58 $1,236.38 $1,229.00 $1,138.85 $1,229.15 $1,180.30 $1,126.68 $1,127.29 $1,089.50
59 $1,284.72 $1,277.04 $1,183.38 $1,277.21 $1,226.44 $1,170.73 $1,171.36 $1,132.09
60 $1,334.96 $1,326.99 $1,229.66 $1,327.16 $1,274.41 $1,216.52 $1,217.17 $1,176.36
61 $1,387.12 $1,378.83 $1,277.70 $1,379.00 $1,324.19 $1,264.04 $1,264.72 $1,222.32
62 $1,387.12 $1,378.83 $1,277.70 $1,379.00 $1,324.19 $1,264.04 $1,264.72 $1,222.32
63 $1,387.12 $1,378.83 $1,277.70 $1,379.00 $1,324.19 $1,264.04 $1,264.72 $1,222.32
64 and over $1,387.12 $1,378.83 $1,277.70 $1,379.00 $1,324.19 $1,264.04 $1,264.72 $1,222.32
(continued)
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Choice Plus insurance rates
Rates displayed are full monthly premium rates based on a single policyholder.
Plan Name
UnitedHealthcare Choice Plus Gold
HSA Gold 1800 2000 2500-1 HSA Gold 2500-1 3000
Plan Code DG-QL DG-RA DG-Q2 DG-QQ DG-Q3
Age
46 $753.97 $701.49 $670.54 $709.88 $719.73
47 $783.46 $728.93 $696.77 $737.65 $747.89
48 $814.19 $757.52 $724.10 $766.58 $777.22
49 $846.14 $787.24 $752.52 $796.66 $807.72
50 $879.32 $818.12 $782.03 $827.91 $839.40
51 $913.73 $850.13 $812.63 $860.30 $872.24
52 $949.37 $883.29 $844.33 $893.86 $906.27
53 $986.24 $917.59 $877.12 $928.57 $941.46
54 $1,024.95 $953.61 $911.55 $965.02 $978.42
55 $1,064.89 $990.77 $947.07 $1,002.63 $1,016.54
56 $1,106.68 $1,029.65 $984.23 $1,041.97 $1,056.43
57 $1,149.69 $1,069.67 $1,022.48 $1,082.47 $1,097.49
58 $1,194.55 $1,111.40 $1,062.38 $1,124.70 $1,140.31
59 $1,241.25 $1,154.85 $1,103.91 $1,168.67 $1,184.89
60 $1,289.79 $1,200.02 $1,147.08 $1,214.38 $1,231.23
61 $1,340.18 $1,246.90 $1,191.89 $1,261.82 $1,279.33
62 $1,340.18 $1,246.90 $1,191.89 $1,261.82 $1,279.33
63 $1,340.18 $1,246.90 $1,191.89 $1,261.82 $1,279.33
64 and over $1,340.18 $1,246.90 $1,191.89 $1,261.82 $1,279.33
Valid for effective dates: Q1 2024.
Rates displayed are per employee rates by age for the Medical/Rx product.
Rates include employer and employee contribution — please contact your HR department for your employee contribution.
To calculate your total family rate (if applicable), add all rates by age for each member of the household. For all dependent children, ages 21 and over, individual rates apply.
For up to three dependent children under 21, add the 0–20 rate. Apply the employee contribution to this total to determine your monthly family premium.
13
Compare plans
1 2 3
Choice insurance plans
UnitedHealthcare Insurance Company
Choice offers broad, national access to physicians and hospitals with no
referrals needed to see a specialist.
How does it work?
You have the choice to see any doctor or specialist without a referral in the
network. The insurance coverage will only pay for visits to network providers,
so you will need to check your plan before visiting a doctor, clinic or hospital.
If you see an out-of-network provider for non-emergency services, you will
be responsible for all costs.
The Choice Network
Choice insurance plans offer national access to over 1,713,250 physicians and
health care professionals, 7,030 hospitals and 67,000 pharmacies.*
Members can
choose any
doctor/specialist
in the network.
Members will not
be covered if they
receive out-of-
network care.
* Network counts based on internal network analysis as of Q3 2023.
14
Compare plans
1 2 3
Choice insurance plans
Plan Name
UnitedHealthcare Choice Gold
0-1 750-1 1500-1 1500-3 1500-2 HSA 1800 2000 HSA 2500-1
HSA HSA HSA
Plan Code DG-RO DG-QM DG-RG DG-RE DG-Q4 DG-QK DG-Q9 DG-QP
Network
Individual
Deductible
$0 $750 $1,500 $1,500 $1,500 $1,800 $2,000 $2,500
Network Family
Deductible
$0 $1,500 $3,000 $3,000 $3,000 $3,600 $4,000 $5,000
Network
Coinsurance
0% 50% 0% 20% 20% 10% 0% 10%
Network
Individual Out-
of-Pocket Limit
$9,450 $6,100 $8,550 $5,800 $8,550 $4,400 $7,000 $4,350
Network Family
Out-of-Pocket
Limit
$18,900 $12,200 $17,100 $11,600 $17,100 $8,800 $14,000 $8,700
24/7 Virtual
Visits
$0 $0 $0 $0 0% $0 $0 $0
PCP Office Visit $30 $50 $35 $30 0%
10% after
deductible
$30
10% after
deductible
Specialist
Office Visit
$60 50% $70 $60
$60 (PD) $120
(non-PD)
10% after
deductible
$60 after
deductible
10% after
deductible
Urgent Care $60
50% after
deductible
$60 $60 $25
10% after
deductible
$60
10% after
deductible
Emergency
Room
$500
50% after
deductible
$350 after
deductible
$350 after
deductible
$350 after
deductible
10% after
deductible
$350 after
deductible
10% after
deductible
Pharmacy
Pharmacy Code N09S N42 K08S K08S K05S N09S K08S K43S
Pharmacy
Deductible
Type
$0 $0
$250
Tier 2,3,4
$250
Tier 2,3,4
$250
Tier 2,3,4
$0
$250
Tier 2,3,4
Combined
Tier 1 $15 $15 $10 $10 $5 $15 $10 $10
Tier 2 $40 $50 $40 $40 $50 $40 $40 $40
Tier 2 Specialty $40 N/A $40 $40 $50 $40 $40 $40
Tier 3 $75
50% up to
$150
$75 $75 $80 $75 $75 $75
Tier 3 Specialty $100 N/A $100 $100 $100 $100 $100 $100
Tier 4 $125
50% up to
$150
$125 $125 $125 $125 $125 $125
Tier 4 Specialty $150 N/A $150 $150 $150 $150 $150 $150
(continued)
15
Compare plans
1 2 3
Choice insurance rates
Rates displayed are full monthly premium rates based on a single policyholder.
Plan Name
UnitedHealthcare Choice Gold
0-1 750-1 1500-1 1500-3 1500-2 HSA 1800 2000 HSA 2500-1
Plan Code DG-RO DG-QM DG-RG DG-RE DG-Q4 DG-QK DG-Q9 DG-QP
Age
0-14 $411.55 $353.51 $392.06 $373.92 $374.16 $396.16 $369.08 $349.54
15 $411.55 $353.51 $392.06 $373.92 $374.16 $396.16 $369.08 $349.54
16 $411.55 $353.51 $392.06 $373.92 $374.16 $396.16 $369.08 $349.54
17 $411.55 $353.51 $392.06 $373.92 $374.16 $396.16 $369.08 $349.54
18 $411.55 $353.51 $392.06 $373.92 $374.16 $396.16 $369.08 $349.54
19 $411.55 $353.51 $392.06 $373.92 $374.16 $396.16 $369.08 $349.54
20 $411.55 $353.51 $392.06 $373.92 $374.16 $396.16 $369.08 $349.54
21 $457.50 $392.98 $435.83 $415.67 $415.93 $440.39 $410.29 $388.56
22 $457.49 $392.97 $435.82 $415.66 $415.92 $440.38 $410.28 $388.55
23 $457.49 $392.97 $435.82 $415.66 $415.92 $440.38 $410.28 $388.55
24 $457.49 $392.97 $435.82 $415.66 $415.92 $440.38 $410.28 $388.55
25 $457.49 $392.97 $435.82 $415.66 $415.92 $440.38 $410.28 $388.55
26 $457.49 $392.97 $435.82 $415.66 $415.92 $440.38 $410.28 $388.55
27 $457.49 $392.97 $435.82 $415.66 $415.92 $440.38 $410.28 $388.55
28 $468.18 $402.16 $446.01 $425.38 $425.65 $450.68 $419.88 $397.64
29 $478.25 $410.81 $455.60 $434.53 $434.80 $460.37 $428.91 $406.19
30 $490.21 $421.08 $466.99 $445.39 $445.67 $471.88 $439.63 $416.34
31 $502.79 $431.89 $478.98 $456.83 $457.12 $483.99 $450.92 $427.03
32 $514.12 $441.62 $489.78 $467.12 $467.41 $494.90 $461.07 $436.65
33 $526.08 $451.89 $501.17 $477.98 $478.28 $506.41 $471.80 $446.81
34 $538.66 $462.70 $513.15 $489.42 $489.73 $518.52 $483.08 $457.50
35 $551.25 $473.51 $525.14 $500.85 $501.17 $530.64 $494.37 $468.19
36 $563.83 $484.32 $537.13 $512.29 $512.61 $542.75 $505.66 $478.88
37 $576.42 $495.13 $549.12 $523.72 $524.05 $554.87 $516.94 $489.57
38 $583.34 $501.08 $555.72 $530.01 $530.35 $561.53 $523.15 $495.44
39 $590.26 $507.03 $562.31 $536.30 $536.64 $568.19 $529.36 $501.32
(continued)
16
1 2 3
Plan Name
UnitedHealthcare Choice Gold
0-1 750-1 1500-1 1500-3 1500-2 HSA 1800 2000 HSA 2500-1
Plan Code DG-RO DG-QM DG-RG DG-RE DG-Q4 DG-QK DG-Q9 DG-QP
Age
40 $613.55 $527.03 $584.49 $557.46 $557.81 $590.61 $550.24 $521.10
41 $637.46 $547.57 $607.27 $579.18 $579.55 $613.62 $571.69 $541.41
42 $662.63 $569.19 $631.25 $602.05 $602.43 $637.85 $594.26 $562.79
43 $688.43 $591.35 $655.83 $625.49 $625.89 $662.69 $617.40 $584.70
44 $715.49 $614.59 $681.61 $650.08 $650.49 $688.74 $641.67 $607.68
45 $743.18 $638.38 $707.99 $675.24 $675.66 $715.39 $666.50 $631.20
46 $772.13 $663.24 $735.56 $701.54 $701.98 $743.26 $692.46 $655.78
47 $802.33 $689.19 $764.34 $728.98 $729.44 $772.33 $719.55 $681.44
48 $833.80 $716.22 $794.31 $757.57 $758.05 $802.62 $747.76 $708.16
49 $866.52 $744.32 $825.48 $787.30 $787.80 $834.12 $777.11 $735.95
50 $900.50 $773.51 $857.86 $818.17 $818.69 $866.83 $807.58 $764.81
51 $935.74 $803.78 $891.43 $850.19 $850.73 $900.75 $839.19 $794.74
52 $972.24 $835.13 $926.20 $883.35 $883.91 $935.88 $871.92 $825.74
53 $1,009.99 $867.57 $962.17 $917.66 $918.24 $972.23 $905.78 $857.81
54 $1,049.64 $901.62 $999.93 $953.68 $954.28 $1,010.39 $941.34 $891.48
55 $1,090.54 $936.76 $1,038.90 $990.84 $991.47 $1,049.76 $978.02 $926.22
56 $1,133.33 $973.51 $1,079.66 $1,029.72 $1,030.37 $1,090.96 $1,016.39 $962.56
57 $1,177.38 $1,011.35 $1,121.63 $1,069.74 $1,070.42 $1,133.36 $1,055.90 $999.97
58 $1,223.32 $1,050.81 $1,165.39 $1,111.48 $1,112.18 $1,177.58 $1,097.10 $1,038.99
59 $1,271.15 $1,091.89 $1,210.95 $1,154.94 $1,155.66 $1,223.62 $1,139.99 $1,079.61
60 $1,320.86 $1,134.59 $1,258.31 $1,200.10 $1,200.86 $1,271.47 $1,184.57 $1,121.83
61 $1,372.46 $1,178.92 $1,307.47 $1,246.99 $1,247.77 $1,321.14 $1,230.85 $1,165.66
62 $1,372.46 $1,178.92 $1,307.47 $1,246.99 $1,247.77 $1,321.14 $1,230.85 $1,165.66
63 $1,372.46 $1,178.92 $1,307.47 $1,246.99 $1,247.77 $1,321.14 $1,230.85 $1,165.66
64 and over $1,372.46 $1,178.92 $1,307.47 $1,246.99 $1,247.77 $1,321.14 $1,230.85 $1,165.66
Choice insurance rates
Rates displayed are full monthly premium rates based on a single policyholder.
Compare plans
Valid for effective dates: Q1 2024.
Rates displayed are per employee rates by age for the Medical/Rx product.
Rates include employer and employee contribution — please contact your HR department for your employee contribution.
To calculate your total family rate (if applicable), add all rates by age for each member of the household. For all dependent children, ages 21 and over, individual rates apply.
For up to three dependent children under 21, add the 0–20 rate. Apply the employee contribution to this total to determine your monthly family premium.
17
1 2 3
OCI HMO plans
Optimum Choice, Inc. (OCI)
OCI HMO plans offer regional access to physicians and hospitals,
network-only coverage and a primary doctor to coordinate care and refer
specialist services.
How does it work?
You pick a primary care physician (PCP) to be your main doctor. Your
PCP gets to know you, helps manage your health care and refers you to
specialists (if needed). The health plan will only pay for visits to network
providers, so you will need to check your plan before visiting a doctor, clinic
or hospital. If you see an out-of-network provider for non-emergency
services, you will be responsible for all costs.
The OCI Network
With almost 32,000 health care providers, 235 hospitals and 3,500
pharmacies in D.C., Delaware, Maryland, Virginia and West Virginia, the OCI
network offers similar regional coverage as the Choice Plus network.
3
Members will need
to choose a PCP.
Members will not
be covered if they
receive out-of-
network care.
3
Compare plans
Network counts based on internal network analysis as of Q3 2023.
18
OCI HMO plans
Plan Name
UnitedHealthcare OCI Gold
500 1500-1 HSA 1800 2000-1 2500-3
HSA HSA
Plan Code DI-AS DG-QD DG-P5 DG-QA DQ-QE
Network
Individual
Deductible
$500 $1,500 $1,800 $2,000 $2,500
Network Family
Deductible
$1,000 $3,000 $3,600 $4,000 $5,000
Network
Coinsurance
20% 20% 10% 20% 20%
Network
Individual Out-of-
Pocket Limit
$5,800 $8,550 $4,400 $6,000 $8,550
Network Family
Out-of-Pocket
Limit
$11,600 $17,100 $8,800 $12,000 $17,100
24/7 Virtual
Visits
$0 $0 $0 $0 0%
PCP Office
Visit
$25 $0 10% after deductible $30 $10
Specialist
Office Visit
$50 $60 (PD) $120 (non-PD) 10% after deductible $60 $40 (PD) $80 (non-PD)
Urgent Care $60 $25 10% after deductible $60 $25
Emergency
Room
$300 $350 after deductible 10% after deductible $350 after deductible 60% after deductible
Pharmacy
Pharmacy Code N44 K05S N09S K08S K43S
Pharmacy
Deductible Type
$0 $250 Tier 2,3,4 $0 $250 Tier 2,3,4 Combined
Tier 1 $15 $5 $15 $10 $10
Tier 2 $50 $50 $40 $40 $40
Tier 2 Specialty N/A $50 $40 $40 $40
Tier 3 $70 $80 $75 $75 $75
Tier 3 Specialty N/A $100 $100 $100 $100
Tier 4 $150 $125 $125 $125 $125
Tier 4 Specialty N/A $150 $150 $150 $150
1 2 3
(continued)
Compare plans
19
1 2 3
OCI HMO rates
Rates displayed are full monthly premium rates based on a single policyholder.
Plan Name
UnitedHealthcare OCI Gold
500 1500-1 HSA 1800 2000-1 2500-3
Plan Code DI-AS DG-QD DG-P5 DG-QA DQ-QE
Age
0-14 $387.10 $357.70 $376.97 $352.52 $336.71
15 $387.10 $357.70 $376.97 $352.52 $336.71
16 $387.10 $357.70 $376.97 $352.52 $336.71
17 $387.10 $357.70 $376.97 $352.52 $336.71
18 $387.10 $357.70 $376.97 $352.52 $336.71
19 $387.10 $357.70 $376.97 $352.52 $336.71
20 $387.10 $357.70 $376.97 $352.52 $336.71
21 $430.31 $397.64 $419.05 $391.88 $374.31
22 $430.30 $397.63 $419.04 $391.87 $374.30
23 $430.30 $397.63 $419.04 $391.87 $374.30
24 $430.30 $397.63 $419.04 $391.87 $374.30
25 $430.30 $397.63 $419.04 $391.87 $374.30
26 $430.30 $397.63 $419.04 $391.87 $374.30
27 $430.30 $397.63 $419.04 $391.87 $374.30
28 $440.37 $406.92 $428.84 $401.03 $383.05
29 $449.84 $415.67 $438.06 $409.66 $391.29
30 $461.08 $426.07 $449.02 $419.90 $401.07
31 $472.92 $437.01 $460.54 $430.68 $411.37
32 $483.57 $446.85 $470.92 $440.38 $420.63
33 $494.82 $457.24 $481.87 $450.62 $430.41
34 $506.66 $468.18 $493.40 $461.40 $440.71
35 $518.50 $479.12 $504.93 $472.18 $451.01
36 $530.33 $490.06 $516.45 $482.96 $461.31
37 $542.17 $501.00 $527.98 $493.74 $471.60
38 $548.68 $507.01 $534.32 $499.67 $477.27
39 $555.19 $513.03 $540.66 $505.60 $482.93
(continued)
Compare plans
20
Plan Name
UnitedHealthcare OCI Gold
500 1500-1 HSA 1800 2000-1 2500-3
Plan Code DI-AS DG-QD DG-P5 DG-QA DQ-QE
Age
40 $577.09 $533.27 $561.99 $525.54 $501.98
41 $599.58 $554.05 $583.89 $546.03 $521.54
42 $623.26 $575.93 $606.95 $567.59 $542.14
43 $647.53 $598.35 $630.58 $589.69 $563.25
44 $672.98 $621.87 $655.37 $612.87 $585.38
45 $699.02 $645.94 $680.73 $636.58 $608.04
46 $726.25 $671.10 $707.24 $661.38 $631.72
47 $754.66 $697.35 $734.91 $687.25 $656.43
48 $784.25 $724.70 $763.73 $714.20 $682.18
49 $815.03 $753.14 $793.70 $742.23 $708.95
50 $846.99 $782.67 $824.83 $771.34 $736.75
51 $880.14 $813.30 $857.11 $801.52 $765.58
52 $914.47 $845.02 $890.54 $832.79 $795.44
53 $949.98 $877.84 $925.12 $865.13 $826.33
54 $987.27 $912.30 $961.44 $899.09 $858.77
55 $1,025.75 $947.85 $998.90 $934.12 $892.24
56 $1,065.99 $985.04 $1,038.10 $970.78 $927.24
57 $1,107.43 $1,023.32 $1,078.44 $1,008.51 $963.28
58 $1,150.63 $1,063.25 $1,120.52 $1,047.85 $1,000.87
59 $1,195.62 $1,104.82 $1,164.33 $1,088.82 $1,040.00
60 $1,242.38 $1,148.03 $1,209.86 $1,131.40 $1,080.67
61 $1,290.91 $1,192.88 $1,257.13 $1,175.60 $1,122.89
62 $1,290.91 $1,192.88 $1,257.13 $1,175.60 $1,122.89
63 $1,290.91 $1,192.88 $1,257.13 $1,175.60 $1,122.89
64 and over $1,290.91 $1,192.88 $1,257.13 $1,175.60 $1,122.89
OCI HMO rates
Rates displayed are full monthly premium rates based on a single policyholder.
Valid for effective dates: Q1 2024.
Rates displayed are per employee rates by age for the Medical/Rx product.
Rates include employer and employee contribution — please contact your HR department for your employee contribution.
To calculate your total family rate (if applicable), add all rates by age for each member of the household. For all dependent children, ages 21 and over, individual rates apply.
For up to three dependent children under 21, add the 0–20 rate. Apply the employee contribution to this total to determine your monthly family premium.
1 2 3
Compare plans
21
1 2 3
Core Essential plans
UnitedHealthcare of the Mid-Atlantic, Inc.
Core Essential plans offer tailored local access only to physicians and hospitals,
network-only coverage and no referrals needed to see a specialist.
Members can choose
any doctor/specialist
in the network.
How does it work?
You have the choice to see any doctor or specialist without a referral in the
tailored network. The health plan will only pay for visits to network providers,
so you will need to check your plan before visiting a doctor, clinic or hospital.
If you see an out-of-network provider for non-emergency services, you will be
responsible for all costs.
The Core Essential Network
The Core Essential network includes 24,880 providers and 87 hospitals in the
Mid-Atlantic region.
4
Information about pharmacy coverage for Core Essential plans:
Prescription drugs on all Core Essential plans are covered under a Prescription
Drug List that features a 4-tiered design to deliver clinical value and competitive
pricing. Tier 1 and Tier 2 medications have cost-share amounts that are lower
than Tier 3 and Tier 4. This helps encourage members to use these more cost-
effective options. Medications that aren’t listed are excluded from coverage.
Exclusions, while potentially disruptive, may help significantly reduce costs. By
covering only those drugs that offer both clinical value and competitive prices,
we are able to provide coverage for treatment options with lower total pharmacy
costs. Members who use an excluded medication have to meet criteria for
review and approval for coverage.
Core Essential plans also feature a tailored pharmacy network that includes
Walgreens, Walmart, Sam’s Club, Costco and Safeway.
To locate pharmacies in the Standard Select Network, visit myuhc.com. Start by
selecting Find a Pharmacy. On the Find a Network Pharmacy page, you can
search for pharmacies by name, ZIP code, city and state, or address.
A list of pharmacies will show at the end of the page. The network participation
status of each pharmacy is listed in the “Network participation” section after each
pharmacy. Be sure to confirm that “Standard Select with Walgreens” is listed.
4
Compare plans
Network counts based on internal network analysis as of Q3 2023
22
Core Essential plans
Plan Name UHC Core Essential Gold 500 UHC Core Essential Gold 750-2
Plan Code DI-AO DG-RD
Network Individual Deductible $500 $750
Network Family Deductible $1,000 $1,500
Network Coinsurance 20% 20%
Network Individual Out-of-Pocket Limit $5,800 $9,000
Network Family Out-of-Pocket Limit $11,600 $18,000
24/7 Virtual Visits $0 $0
PCP Office Visit $25 $30
Specialist Office Visit $50 $60 (PD) $65 (non-PD)
Urgent Care $60 $60
Emergency Room $300 $400 after deductible
Pharmacy
Pharmacy Code N44 N09S
Pharmacy Deductible Type $0 $0
Tier 1 $15 $15
Tier 2 $50 $40
T
ier 2 Specialty N/A $40
Tier 3 $70 $75
Tier 3 Specialty N/A $100
Tier 4 $150 $125
Tier 4 Specialty N/A $150
1 2 3
Compare plans
23
1 2 3
Plan Name
UHC Core Essential
Gold 500
UHC Core Essential
Gold 750-2
Age DI-AO DG-RD
Compare plans
Core Essential plans
Rates displayed are full monthly premium rates based on a single policyholder.
Plan Name
UHC Core Essential
Gold 500
UHC Core Essential
Gold 750-2
Age DI-AO DG-RD
0-14 $373.52 $345.80
15 $373.52 $345.80
16 $373.52 $345.80
17 $373.52 $345.80
18 $373.52 $345.80
19 $373.52 $345.80
20 $373.52 $345.80
21 $415.22 $384.40
22 $415.21 $384.39
23 $415.21 $384.39
24 $415.21 $384.39
25 $415.21 $384.39
26 $415.21 $384.39
27 $415.21 $384.39
28 $424.92 $393.38
29 $434.06 $401.84
30 $444.91 $411.89
31 $456.33 $422.46
32 $466.61 $431.98
33 $477.46 $442.03
34 $488.89 $452.60
35 $500.31 $463.18
36 $511.73 $473.75
37 $523.16 $484.33
38 $529.44 $490.14
39 $535.72 $495.96
40 $556.85 $515.52
41 $578.55 $535.61
42 $601.40 $556.76
43 $624.82 $578.44
44 $649.37 $601.18
45 $674.50 $624.44
46 $700.78 $648.76
47 $728.19 $674.14
48 $756.75 $700.58
49 $786.45 $728.07
50 $817.29 $756.63
51 $849.27 $786.24
52 $882.40 $816.90
53 $916.66 $848.63
54 $952.64 $881.94
55 $989.77 $916.31
56
$1,028.61 $952.26
57 $1,068.58 $989.27
58 $1,110.28 $1,027.87
59 $1,153.68 $1,068.05
60 $1,198.80 $1,109.83
61 $1,245.63 $1,153.18
62 $1,245.63 $1,153.18
63 $1,245.63 $1,153.18
64 and over $1,245.63 $1,153.18
Valid for effective dates: Q1 2023.
Rates displayed are per employee rates by age for the Medical/Rx product.
Rates include employer and employee contribution — please contact your HR department for your employee contribution.
To calculate your total family rate (if applicable), add all rates by age for each member of the household. For all dependent children, ages 21 and over, individual rates apply.
For up to three dependent children under 21, add the 0–20 rate. Apply the employee contribution to this total to determine your monthly family premium.
24
1 2 3
UnitedHealthcare Navigate® HMO plans
UnitedHealthcare of the Mid-Atlantic, Inc.
UnitedHealthcare Navigate® HMO plans offer tailored local access only to
physicians and hospitals, network-only coverage and a primary doctor to
coordinate care and refer specialist services.
How does it work?
You pick a primary care physician (PCP) to be your main doctor. Your PCP
gets to know you, helps manage your health care and refers you to specialists
(if needed). The health plan will only pay for visits to network providers, so
you will need to check your plan before visiting a doctor, clinic or hospital.
If you see an out-of-network provider for non-emergency services, you will
be responsible for all costs.
The Navigate Network
The Navigate network includes 24,880 providers and 87 hospitals in the
Mid-Atlantic region.
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Members will need
to choose a PCP.
Members will not
be covered if they
receive out-of-
network care.
Compare plans
Information about pharmacy coverage for Navigate plans:
Prescription drugs on all available Navigate plans are covered under a
Prescription Drug List that features a 4-tiered design to deliver clinical value
and competitive pricing. Tier 1 and Tier 2 medications have cost-share
amounts that are lower than Tier 3 and Tier 4. This helps encourage members
to use these more cost-effective options. Medications that aren’t listed are
excluded from coverage. Exclusions, while potentially disruptive, may help
significantly to reduce costs. By covering only those drugs that offer both
clinical value and competitive prices, we are able to provide coverage for
treatment options with lower total pharmacy costs. Members who use an
excluded medication have to meet criteria for review and approval for coverage.
Navigate plans also feature a tailored pharmacy network that includes
Walgreens, Walmart, Sam’s Club, Costco and Safeway.
To locate pharmacies in the Standard Select Network visit myuhc.com. Start
by selecting Find a Pharmacy. On the Find a Network Pharmacy page, you
can search for pharmacies by name, ZIP code, city and state, or address.
A list of pharmacies will show at the end of the page. The network participation
status of each pharmacy is listed in the “Network participation” section after
each pharmacy. Be sure to confirm that “Standard Select with Walgreens”
is listed.
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Network counts based on internal network analysis as of Q3 2023
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1 2 3
UnitedHealthcare Navigate HMO plans
Plan Name UHC Navigate Gold 750
Plan Code DG-QY
Network Individual Deductible $750
Network Family Deductible $1,500
Network Coinsurance 20%
Network Individual Out-of-Pocket Limit $8,900
Network Family Out-of-Pocket Limit $17,800
24/7 Virtual Visits $0
PCP Office Visit $30
Specialist Office Visit $60
Urgent Care $60
Emergency Room $400 after deductible
Pharmacy
Pharmacy Code N09S
Pharmacy Deductible Type $0
Tier 1 $15
Tier 2 $40
Tier 2 Specialty $40
Tier 3 $75
Tier 3 Specialty $100
Tier 4 $125
Tier 4 Specialty $150
Compare plans
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1 2 3
UHC Navigate Gold 750
Age DG-QY
Compare plans
UnitedHealthcare Navigate rates
Rates displayed are full monthly premium rates based on a single policyholder.
UHC Navigate Gold 750
Age DG-QY
0-14 $330.13
15 $330.13
16 $330.13
17 $330.13
18 $330.13
19 $330.13
20 $330.13
21 $366.99
22 $366.98
23 $366.98
24 $366.98
25 $366.98
26 $366.98
27 $366.98
28 $375.56
29 $383.64
30 $393.23
31 $403.33
32 $412.41
33 $422.00
34 $432.10
35 $442.20
36 $452.29
37 $462.39
38 $467.94
39 $473.49
40 $492.17
41 $511.35
42 $531.54
43 $552.24
44 $573.95
45 $596.16
46 $619.38
47 $643.61
48 $668.85
49 $695.10
50 $722.35
51 $750.62
52 $779.90
53 $810.19
54 $841.99
55 $874.80
56 $909.13
57 $944.46
58 $981.31
59 $1,019.68
60 $1,059.55
61 $1,100.95
62 $1,100.95
63 $1,100.95
64 and over $1,100.95
Valid for effective dates: Q1 2023.
Rates displayed are per employee rates by age for the Medical/Rx product.
Rates include employer and employee contribution — please contact your HR department for your employee contribution.
To calculate your total family rate (if applicable), add all rates by age for each member of the household. For all dependent children, ages 21 and over, individual rates apply.
For up to three dependent children under 21, add the 0–20 rate. Apply the employee contribution to this total to determine your monthly family premium.
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3
Sign up
Find out what happens next
Check out the Members of Congress/Staff page at the Office of Personnel Management website.
• Visit: opm.gov/healthcare-insurance
• Click Changes in Health Coverage under the Insurance tab
• Click Eligibility & Enrollment in the left-hand column
• Click the Members of Congress/Staff tab
If you would like more information on UnitedHealthcare networks and to access sample policies, visit uhc.com/congress.
If you want more benefit information on all UnitedHealthcare plans available to you, and to sign up for coverage,
visit dchealthlink.com.
Exclusions and limitations:
*
• Charges in excess of Eligible
Expenses or in excess of any
specified limitation
• Pediatric dental and vision limited
to benefits as described in the
medical contract
• Outpatient prescription drug
products obtained from a non-
Network Pharmacy
• Coverage for prescription drug
products, which is less than or
exceeds the supply limit
• Prescription drug products dispensed
outside the United States, except as
required for emergency treatment
• Any product dispensed for the
purpose of appetite suppression
or weight loss
• Prescription drug products when
prescribed to treat infertility
• Certain prescription drug products
for smoking cessation
• Prescription drug products not
included on Prescription Drug List
• Compounded prescriptions
• Over-the-counter prescription drugs
unless we have designated the over-
the-counter medication as eligible
for coverage
• Growth hormone for children with
familial short stature
• Any medication that is used for the
treatment of erectile dysfunction or
sexual dysfunction
• A prescription drug product that
contains marijuana, including
medical marijuana
• Dental products including, but
not limited to, prescription
fluoride topicals
• Cosmetic procedures
and medications
• In-vitro fertilization
• Obesity surgery
• Services performed by a provider
who is a family member or shares
your same legal residence
• Physical, psychiatric or psychological
exams, testing, vaccinations,
immunizations or treatments that are
otherwise covered under this Policy
when required solely for purposes of
school, sports or camp, travel, career
or employment, insurance, marriage,
adoption, related to judicial or
administrative proceedings or orders,
conducted for purposes of medical
research, or are required to obtain or
maintain a license of any type.
• Services or supplies that are
experimental or investigational,
except routine costs associated
with qualifying clinical trials
* This list may not be all inclusive and is subject to change. Please refer to your plan coverage documents for a full list of exclusions and limitations.
28
If you, or someone you’re helping, has questions about the
Health Insurance Marketplace, you have the right to get help and
information in your language at no cost. To talk to an interpreter, call
1-877-856-2430.
Si usted, o alguien a quien usted está ayudando, tiene preguntas
acerc
a de Health Insurance Marketplace, tiene derecho a obtener
a
yuda e información en su idioma sin costo alguno. Para hablar con
un intérprete, llame al 1-877-856-2430.
እርስዎ፣ ወይም እርስዎ የሚያግዙት ግለሰብ፣ ስለ Health Insurance
Marke
tplace ጥያቄ ካላችሁ፣ ያለ ምንም ክፍያ በቋንቋዎ እርዳታና
የማግኘት መብት አላችሁ። ከአስተርጓሚ ጋር ለመነጋገር፣ 1-877-856-2430
ይደውሉ።
如果您，或是您正在協助的對象，有關於
Health Insurance
Marke
tplace 方面的問題，您有權利免費以您的母語得到幫助和訊
息。洽詢一位翻譯員，請撥電話1-877-856-2430。
S
i vous, ou une personne que vous aidez, av
ez des questions à
propos du Health Insurance Marketplace, vous avez le droit d’obtenir
grat
uitement de l’aide et des renseignements dans votre langue.
Pour parler à un interprète, appelez le 1-877-856-2430.
Kung ikaw, o ang iyong tinutulungan, a
y may mga katanungan
tungkol sa Health Insurance Marketplace, may karapatan kang
makakuha n
g tulong at impormasyon sa iyong wika nang walang
gastos. Upang makipag-usap sa isang tagasalin ng wika, tumawag
sa 1-877-856-2430.
Если у вас или лица, которому вы помогаете, имеются вопросы
по поводу
Health Insurance Marketplace, то вы имеете право
на бесплатное получение помощи и информации на ваше
м
языке. Для разговора с переводчиком позвоните по телефону
1-877-856-2430.
Se você, ou alguém a quem você está ajudando, tem per
guntas
sobre o Health Insurance Marketplace, você tem o direito de obter
ajuda e inf
ormação em seu idioma e sem custos. Para falar com um
intérprete, ligue para 1-877-856-2430.
Se tu o qualcuno che stai aiutando avete domande su Health
Insurance Mark
etplace, avete il diritto di ottenere aiuto e informazioni
nella v
ostra lingua gratuitamente. Per parlare con un interprete,
potete chiamare 1-877-856-2430.
Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Health
Insurance Marke
tplace, quý vị sẽ có quyền được giúp và c
ó thêm
thông n bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một
thông dịch viên, xin gọi 1-877-856-2430.
I bale we, tole mut u ye hola, a gwee mbar
ga inyu Health Insurance
Marketplace, U gwee Kunde I kosna mahola ni biniiguene i hop
won
g nni nsaa wogui wo. I Nyu ipot ni mut a nla koblene we hop,
sebel 1-877-856-2430.
Ọ bụrụ gị, ma o bụ onye I na eyere-aka, nwere ajụjụ gbasara Health
Insur
ance Marketplace, I nwere ohere iwen
ta nye maka na ọmụma
na asụsụ gị na akwughi ụgwọ. I chọrọ I kwụrụ onye-ntapịa okwu, kpọ
1-877-856-2430.
Bí ìwọ, tàbí ẹnikẹni o n ranlọwọ, bá ní ibeere nípa Health Insurance
Marketplace
, o ní ẹtọ la gba iranwọ à
ìtónilé ní èdè rẹ láìsanwó.
Lá bá ongbufọ kan sọrọ, pè sórí 1-877-856-2430.
যদি আপনি, অথবা আপনি অন্য কাউকে সহায়তা করছেন, তাদের Health Insurance
Marketplace সম্পর্কে প্রশ্ন থাকলে, আপনার অধিকার আছে বিনা খরচে সাহায্য পাবার
, এবং আপনার নিজস্ব ভাষাতে তথ্য জানবার। অনুবাদকের সাথে কথা বলার জন্য, কল
করুন 1-877-856-2430.
ご本人您、またはお客您の身の回りの方でも、
Health Insurance
Marketplace についてご質問がございましたら、ご希望
の言語でサポ您トを受けたり、情報を入手したりすること
ができます。料金はかかりません。通您とお話される場
合、1-877-856-2430までお電話ください。
Falls Sie oder jemand, dem Sie helfen, Fragen zum Health
Insurance Marketplace haben, haben Sie das Recht, kostenlose
Hilfe und Infor
mationen in Ihrer Sprache zu erhalten. Um mit
einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer
1-877-856-2430 an.
إذا كان لديك أو لدى شخص تساعده أسئلة بخصوص Health Insurance
Marke
tplace، فلديك الحق في الحصول على المساعدة والمعلومات
الضرورية بلغتك من دون أي تكلفة. للتحدث مع مترجم اتصل بـ
1-877-856-2430.
UnitedHealthcare Insurance Company, UnitedHealthcare of the
Mid-Atlantic and Optimum Choice Inc., and their affiliates do not treat
members differently because of sex, age, race, color, disability or
national origin.
If you think you were treated unfairly because of your sex, age, race,
color, dis
ability or national origin, you can send a complaint to:
Civil Rights Coordinator
United HealthCare Civil Rights Grievance
P.O. Box 30608
Salt Lake City, UT 84130
You must send the complaint within 60 days of when you found out
about it. A decision will be sent t
o you within 30 days. If you disagree
with the decision, you have 15 days to ask us to look at it again.
If you need help with your complaint, please call the toll-free member
phone number listed on y
our health plan ID card, TTY 711, Monday
through Friday, 8 a.m. to 8 p.m. You can also file a complaint with the
U.S. Dept. of Health and Human Services.
Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms are available at http://www.hhs.gov/ocr/office/file/
index.html.
P
hone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)
Mail: U
.S. Dept. of Health and Human Services
. 200 Independence
Avenue, SW Room 509F, Hubert H. Humphrey Building, Washington,
D.C. 20201
We provide free language services. We provide free services to help
you communic
ate with us, such as letters in other languages or large
print. Or, you can ask for an interpreter. To ask for help, please call the
toll-free member phone number listed on your health plan ID card TTY
711, Monday through Friday, 8 a.m. to 8 p.m. ET.
Learn more
To learn more about UnitedHealthcare plans, visit uhc.com/congress or call 1-877-856-2430.
1
C
ognitive Behavioral Therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems, including depression, anxiety disorders, alcohol and drug use problems,
marital problems, eating disorders and severe mental illness. apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral. Accessed 09/30/2023.
2
bhsonline.com/ending-mental-health-stigma-in-the-workplace/. Accessed 09/30/2023.
App Store is a registered trademark of Apple, Inc. All trademarks are the property of their respective owners.
The AbleTo mobile application should not be used for urgent care needs. If you are experiencing a crisis or need emergency care, call 911 or go to the nearest emergency room. The Self Care information contained
in the AbleTo mobile application is for educational purposes only; it is not intended to diagnose problems or provide treatment and should not be used on its own as a substitute for care from a provider. AbleTo Self
Care is available to members ages 13+ at no additional cost as part of your benefit plan. Self Care is not available for all groups in District of Columbia, Maryland, New York, Pennsylvania, Virginia or West Virginia and is
subject to change. Refer to your plan documents for specific benefit coverage and limitations or call the toll-free member phone number on your health plan ID card. Participation in the program is voluntary and subject
to the terms of use contained in the mobile application.
The UnitedHealth Premium® designation program is a resource for informational purposes only. Designations are displayed in UnitedHealthcare online physician directories at myuhc.com®. You should always visit
myuhc.com for the most current information. Premium designations are a guide to choosing a physician and may be used as one of many factors you consider when choosing a physician. If you already
have a physician, you may also wish to confer with them for advice on selecting other physicians. Physician evaluations have a risk of error and should not be the sole basis for selecting a physician.
Please visit myuhc.com for detailed program information and methodologies.
Care Cash provides a pre-loaded debit card that can be used for certain health care expenses. If the card is used for ineligible 213(d) expenses, individuals may incur tax obligations and should consult an appropriate
tax professional to determine if they have such obligations. The information provided in connection with Care Cash is for general informational purposes only and is not intended to be nor should be construed as
medical advice. Individuals should consult an appropriate health care professional to determine what may be right for them.
24/7 Virtual Visits is a service available with a Designated Virtual Network Provider via video, or audio-only where permitted under state law. Unless otherwise required, benefits are available only when services are
delivered through a Designated Virtual Network Provider. 24/7 Virtual Visits are not intended to address emergency or life-threatening medical conditions and should not be used in those circumstances. Services may
not be available at all times, or in all locations, or for all members. Check your benefit plan to determine if these services are available.
Certain preventive care items and services, including immunizations, are provided as specified by applicable law, including the Patient Protection and Affordable Care Act (ACA), with no cost-sharing to you. These
services may be based on your age and other health factors. Other routine services may be covered under your plan, and some plans may require copayments, coinsurance or deductibles for these benefits. Always
review your benefit plan documents to determine your specific coverage details.
The UnitedHealthcare plan with Health Savings Account (HSA) is a qualifying high-deductible health plan (HDHP) that is designed to comply with IRS requirements so eligible enrollees may open a Health Savings
Account (HSA) with a bank of their choice or through Optum Bank®, Member FDIC. The HSA refers only and specifically to the Health Savings Account that is provided in conjunction with a particular bank, such as
Optum Bank, and not to the associated HDHP.
UnitedHealthcare Rewards is a voluntary program. The information provided under this program is for general informational purposes only and is not intended to be nor should be construed as medical advice.
You should consult an appropriate health care professional before beginning any exercise program and/or to determine what may be right for you. Receiving an activity tracker, certain credits and/or rewards and/
or purchasing an activity tracker with earnings may have tax implications. You should consult with an appropriate tax professional to determine if you have any tax obligations under this program, as applicable. If any
fraudulent activity is detected (e.g., misrepresented physical activity), you may be suspended and/or terminated from the program. If you are unable to meet a standard related to health factor to receive a reward under
this program, you might qualify for an opportunity to receive the reward by different means. You may call us toll-free at 1-866-230-2505 or at the number on your health plan ID card, and we will work with you (and, if
necessary, your doctor) to find another way for you to earn the same reward. Rewards may be limited due to incentive limits under applicable law. Components subject to change. This program is not available for fully
insured members in Hawaii, Vermont and Puerto Rico nor available to level funded members in District of Columbia, Hawaii, Vermont and Puerto Rico.
All UnitedHealthcare members can access a cost estimate online or on the mobile app. None of the cost estimates are intended to be a guarantee of your costs or benefits. Your actual costs may vary. When accessing
a cost estimate, please refer to the website or mobile application terms of use under Find Care & Costs section.
UnitedHealthcare policies may have exclusions or limitations or terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, contact your broker, consultant
or UnitedHealthcare Representative.
Insurance coverage provided by or through UnitedHealthcare Insurance Company. Administrative services provided by United HealthCare Services, Inc. Health Plan coverage provided by or through Optimum Choice,
Inc. (and MAMSI Life and Health Insurance Company for out-of-network benefits). Health plan coverage provided by UnitedHealthcare of the Mid-Atlantic, Inc.
B2C EI232693256.0 10/23 © 2023 United HealthCare Services, Inc. All Rights Reserved. 23-2693850
