Colorado Medical Benefits Chart

Colorado

United Prudential

POS HMO HMO POS

SERVICE In-Network Out-Of-Network Low Low High In-Network Out-Of-Network

PCP Required? No No No Yes Yes Yes No

Referrals Required? No No No Yes Yes Yes No

Annual Deductible None $500 None None None None $300

Max Out-of-Pocket(excluding deductible) None $3,000 None None None N/A $4,500

Co-Insurance % N/A 70% N/A N/A N/A N/A 70%

Lifetime Maximum Unlimited $1,000,000 Unlimited Unlimited Unlimited Unlimited $1,000,000

Office Visits $15 copay 70% $15 copay $15 copay $10 copay $15 copay 70%

Maternity Prenatal Care $15 initial visit only 70% $15 initial visit only $15 initial visit only $10 initial visit only $15 initial visit only 70%

Maternity Delivery $250 copay 70% $250 copay $500 copay 100% 100% 70%

Inpatient Hospital $250 copay 70% $250 copay $500 copay 100% 100% 70%

Outpatient Hospital $50 copay 70% $50 copay 100% 100% 100% 70%

Lab & X-Rays 100% 70% 100% 100% 100% 100% 70%

Hospital ER (waived if admitted) $50 copay 70% $50 copay $50 copay $50 copay $50 copay 70%

Ambulance 100% 70% 100% 100% 100% 100% 70%

Mental Health Inpatient $250 copay 50% $250 copay $500 copay 100% 100% for first 15 days; 60% for next 15 days; 50% for remaining 15 days 50%

Annual Inpatient Maximum 45 Days 45 Days 45 Days 45 Days 45 Days 45 Days 45 Days

Mental Health Outpatient $25 copay 50% $25 copay $15 copay $10 copay 100% for first 3 visits; 70% thereafter 50% to $1,000 ; thereafter $40/visit max

Annual Outpatient Maximum 20 visits per year 20 visits per year 20 visits per year 20 visits 20 visits n/a $2,500

Substance Abuse Inpatient $250 copay Not covered $250 copay $500 copay 100% 100% for first 15 days; 60% for next 15 days; 50% for remaining 15 days 50%

Annual Inpatient Maximum 45 Days Not covered 45 Days 45 Days 45 Days 45 Days 45 Days

Substance Abuse Outpatient $25 copay Not covered $25 copay $15 copay $10 copay 100% for first 3 visits; 70% thereafter 50% to $1,000 ; thereafter $40/visit max

Annual Outpatient Maximum $1,000 Not covered $1,000 20 visits per year/$2,500 20 visits per year/$2,500 $2,500 $2,500

Prescription Drugs $5 copay generic/$10 copay brand Not covered $5 copay generic/$10 copay brand $5 copay generic/$15 for brand $5 copay generic/$15 for brand $5 copay generic/$10 for brand 70% after $50 deductible

Chiropractic Care $10 copay; 20 visits Not covered None $15 copay $10 copay $15 copay 70%

Colorado
	United			Prudential
	POS		HMO	HMO		POS
SERVICE	In-Network	Out-Of-Network	Low	Low	High	In-Network	Out-Of-Network
PCP Required?	No	No	No	Yes	Yes	Yes	No
Referrals Required?	No	No	No	Yes	Yes	Yes	No
Annual Deductible	None	$500	None	None	None	None	$300
Max Out-of-Pocket(excluding deductible)	None	$3,000	None	None	None	N/A	$4,500
Co-Insurance %	N/A	70%	N/A	N/A	N/A	N/A	70%
Lifetime Maximum	Unlimited	$1,000,000	Unlimited	Unlimited	Unlimited	Unlimited	$1,000,000
Office Visits	$15 copay	70%	$15 copay	$15 copay	$10 copay	$15 copay	70%
Maternity Prenatal Care	$15 initial visit only	70%	$15 initial visit only	$15 initial visit only	$10 initial visit only	$15 initial visit only	70%
Maternity Delivery	$250 copay	70%	$250 copay	$500 copay	100%	100%	70%
Inpatient Hospital	$250 copay	70%	$250 copay	$500 copay	100%	100%	70%
Outpatient Hospital	$50 copay	70%	$50 copay	100%	100%	100%	70%
Lab & X-Rays	100%	70%	100%	100%	100%	100%	70%
Hospital ER (waived if admitted)	$50 copay	70%	$50 copay	$50 copay	$50 copay	$50 copay	70%
Ambulance	100%	70%	100%	100%	100%	100%	70%
Mental Health Inpatient	$250 copay	50%	$250 copay	$500 copay	100%	100% for first 15 days; 60% for next 15 days; 50% for remaining 15 days	50%
Annual Inpatient Maximum	45 Days	45 Days	45 Days	45 Days	45 Days	45 Days	45 Days
Mental Health Outpatient	$25 copay	50%	$25 copay	$15 copay	$10 copay	100% for first 3 visits; 70% thereafter	50% to $1,000 ; thereafter $40/visit max
Annual Outpatient Maximum	20 visits per year	20 visits per year	20 visits per year	20 visits	20 visits	n/a	$2,500
Substance Abuse Inpatient	$250 copay	Not covered	$250 copay	$500 copay	100%	100% for first 15 days; 60% for next 15 days; 50% for remaining 15 days	50%
Annual Inpatient Maximum	45 Days	Not covered	45 Days	45 Days	45 Days	45 Days	45 Days
Substance Abuse Outpatient	$25 copay	Not covered	$25 copay	$15 copay	$10 copay	100% for first 3 visits; 70% thereafter	50% to $1,000 ; thereafter $40/visit max
Annual Outpatient Maximum	$1,000	Not covered	$1,000	20 visits per year/$2,500	20 visits per year/$2,500	$2,500	$2,500
Prescription Drugs	$5 copay generic/$10 copay brand	Not covered	$5 copay generic/$10 copay brand	$5 copay generic/$15 for brand	$5 copay generic/$15 for brand	$5 copay generic/$10 for brand	70% after $50 deductible
Chiropractic Care	$10 copay; 20 visits	Not covered	None	$15 copay	$10 copay	$15 copay	70%