Page 6 - 2017-18 Optimas Benefits Guide

UHC Medical and Prescription Drug Plan Options

Consumer Driven Plan 1 Consumer Driven Plan 2
In-Network Out-of-Network In-Network Out-of-Network
Plan Year Deductible*
Individual $1,300 $2,600 $2,000 $4,000
Family $2,600 $5,200 $4,000 $8,000
Out-of-Pocket Maximum Includes Deductibles
Individual $3,000 $6,000 $3,500 $7,000
Family $6,000 $12,000 $6,850 $14,000
Wellness/Preventive
100% covered No coverage 100% covered No coverage
Physician Ofice Visits
Primary Care 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Virtual Visits 20% after deductible No coverage 20% after deductible No coverage
Specialist 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Urgent Care
20% after deductible 30% after deductible 20% after deductible 30% after deductible
Hospital Services
Inpatient 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Outpatient 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Emergency Room 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Mental Health and Substance Abuse
Inpatient 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Outpatient 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Ofice Visits 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Other Care
Skilled Nursing Care 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Home Healthcare 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Hospice Care 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Durable Medical 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Equipment
Chiropractic Care (Up to 20 visits per calendar year)
20% after deductible 30% after deductible 20% after deductible 30% after deductible
Prescription Drugs**
Preventive Drugs 100% 30% after deductible 100% 30% after deductible
Retail—Supply Limit 20% after deductible 30% after deductible 20% after deductible 30% after deductible
(31-day supply)
Mail Order—Supply 20% after deductible No coverage 20% after deductible No coverage
Limit (90-day supply)
* Deductibles are non-embedded which means the full family deductible must be satisied before your plan will share your costs through
coinsurance.

** For more prescription drug information, please see page 7.

6 2017–18 Benefits Enrollment