Results for Medical

 HSA In-NetworkHSA Out-of-Network
Deductible

You
$2,000

You + family
$4,000

You
$4,000

You + family
$8,000

Money from Rockwell Automation

You
$500

You + family
$1,000

You
$500
You + family
$1,000

The Plan Pays: Preventive Care

100% no deductible

60% after deductible

The Plan Pays: Doctor Office Visits

80% after deductible

85% (after deductible) for Tier 1 providers and Freestanding Facilities

60% after deductible

The Plan Pays: Urgent Care Clinic

80% after deductible

85% (after deductible) for Tier 1 providers and Freestanding Facilities

60% after deductible

The Plan Pays: Emergency Room

80% after deductible

85% (after deductible) for Tier 1 providers and Freestanding Facilities

60% after deductible

The Plan Pays: Hospital Stay

80% after deductible

85% (after deductible) for Tier 1 providers and Freestanding Facilities

60% after deductible

Out-of-Pocket Maximum

You
$4,000

You + family
$8,000

You
$8,000

You + family
$16,000

Reasonable and Customary Charges: The plan pays up to reasonable and customary (R&C) charges for out of network care. You are responsible for any cost difference if your expenses are more than the R&C limits.

Using Tier 1 Providers and Freestanding Facilities

Using Tier 1 providers and Freestanding Facilities is optional. The Tier 1 designation helps you find providers known for offering the best combination of quality and cost. (The availability of Tier 1 providers varies by location.) Freestanding Facilities are outpatient, diagnostic or ambulatory centers, or independent laboratories in the Choice Plus network that perform services and submit claims as freestanding entities and not as hospitals.

Out-of-Pocket Maximum

Once your expenses reach a certain amount, Rockwell Automation will pay 100% of all remaining eligible costs for the rest of the year. You may pay additional amounts out of pocket for prescription drugs in the Broad Access Plan and High-Performance Plan options.

Use Your Network’s Provider Search Tool

To look up providers, log in to myuhc.com.