Page 5 - Guide
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UnitedHealthcare UnitedHealthcare 2017 Beneits Enrollment
Qualified High Deductible Health Plan—
Traditional PPO HSA
In-Network Out-of-Network In-Network Out-of-Network Important
Prescription Drugs Preventive Drugs By USPSTF Covered Insurance
100% Definitions
Retail— 31 Days 31 Days Embedded Deductible—
Supply Limit meaning an individual
Tier 1 $10 copay $10 copay $10 copay after $10 copay after deductible or out-of-pocket
deductible deductible
Tier 2 $35 copay $35 copay $35 copay after $35 copay after maximum can be satisfied
deductible deductible without the full family
Tier 3 $70 copay $70 copay $60 copay after $60 copay after deductible or out-of-pocket
deductible deductible maximum being satisfied.
Mail Order— 90 Days Not covered 90 Days Not covered Non-Embedded
Supply Limit Deductible—meaning no
Tier 1 $25 copay Not covered $25 copay after Not covered individual family member’s
deductible deductible or out-of-pocket
Tier 2 $87.50 copay Not covered $87.50 copay after Not covered maximum is satisfied until the
deductible full family deductible or out-of-
Tier 3 $175 copay Not covered $150 copay after Not covered pocket maximum is satisfied.
deductible One member of the family can
meet the full family deductible
or out-of pocket maximum or it
can be a combination.
Coinsurance—the members’
When you elect the High Deductible Health Plan—HSA, you also receive a company-paid portion of cost share once the
Critical Illness plan provided through Unum. This plan is intended to serve as a cushion embedded or non-embedded
against unexpected costs which may arise during your time on the plan. If diagnosed deductible is satisfied.
with any of the below illnesses, Unum will pay you the amount shown on a tax-free basis.
To receive the benefit, you must file a claim and submit medical documentation. Please
contact HR with questions.
X $5,000 benefit* paid upon occurrence, diagnosis or onset of cancer, heart attack,
stroke, end stage renal (kidney) failure, major organ failure, permanent paralysis as
the result of a covered accident, coma as the result of severe traumatic brain injury,
blindness, benign brain tumor, occupational HIV (child benefit is $1,250)
X $2,500 benefit paid upon occurrence or diagnosis of carcinoma in situ or coronary
artery bypass surgery (child benefit is $625)
X $1,250 benefit for covered dependent children paid upon the occurrence, diagnosis
or onset of cerebral palsy, cleft lip or palate cystic fibrosis, down syndrome, or spina
bifida
* Beneit payable for employee and dependents covered on the High Deductible Health Plan.
Spouse beneit equals amount shown above.
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Qualified High Deductible Health Plan—
Traditional PPO HSA
In-Network Out-of-Network In-Network Out-of-Network Important
Prescription Drugs Preventive Drugs By USPSTF Covered Insurance
100% Definitions
Retail— 31 Days 31 Days Embedded Deductible—
Supply Limit meaning an individual
Tier 1 $10 copay $10 copay $10 copay after $10 copay after deductible or out-of-pocket
deductible deductible
Tier 2 $35 copay $35 copay $35 copay after $35 copay after maximum can be satisfied
deductible deductible without the full family
Tier 3 $70 copay $70 copay $60 copay after $60 copay after deductible or out-of-pocket
deductible deductible maximum being satisfied.
Mail Order— 90 Days Not covered 90 Days Not covered Non-Embedded
Supply Limit Deductible—meaning no
Tier 1 $25 copay Not covered $25 copay after Not covered individual family member’s
deductible deductible or out-of-pocket
Tier 2 $87.50 copay Not covered $87.50 copay after Not covered maximum is satisfied until the
deductible full family deductible or out-of-
Tier 3 $175 copay Not covered $150 copay after Not covered pocket maximum is satisfied.
deductible One member of the family can
meet the full family deductible
or out-of pocket maximum or it
can be a combination.
Coinsurance—the members’
When you elect the High Deductible Health Plan—HSA, you also receive a company-paid portion of cost share once the
Critical Illness plan provided through Unum. This plan is intended to serve as a cushion embedded or non-embedded
against unexpected costs which may arise during your time on the plan. If diagnosed deductible is satisfied.
with any of the below illnesses, Unum will pay you the amount shown on a tax-free basis.
To receive the benefit, you must file a claim and submit medical documentation. Please
contact HR with questions.
X $5,000 benefit* paid upon occurrence, diagnosis or onset of cancer, heart attack,
stroke, end stage renal (kidney) failure, major organ failure, permanent paralysis as
the result of a covered accident, coma as the result of severe traumatic brain injury,
blindness, benign brain tumor, occupational HIV (child benefit is $1,250)
X $2,500 benefit paid upon occurrence or diagnosis of carcinoma in situ or coronary
artery bypass surgery (child benefit is $625)
X $1,250 benefit for covered dependent children paid upon the occurrence, diagnosis
or onset of cerebral palsy, cleft lip or palate cystic fibrosis, down syndrome, or spina
bifida
* Beneit payable for employee and dependents covered on the High Deductible Health Plan.
Spouse beneit equals amount shown above.
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