Page 4 - 2016 Enrollment
P. 4
Medical Provider Search
2016 Medical Benefits
HSA Plan
Annual Deductible In-Network Out-of-Network
Employee only $1,500 $10,000
Employee + spouse $2,750 $20,000
UMR Provider Search Employee + child(ren) $2,750 $20,000
To get the highest level of coverage Family $3,500 $20,000
from your plan, use “In-Network” Out-of-Pocket Limit (Includes Deductible)
participating health care providers. Employee only $2,450 $20,000
Receiving services from a participating Employee + spouse $4,400 $40,000
“In-Network” provider reduces your out- Employee + child(ren) $4,400 $40,000
of-pocket healthcare costs. To conirm Family $5,400 $40,000
if your provider is participating or to Lifetime maximum Unlimited
search for providers, just follow these Hospital
simple steps. Inpatient 90% after ded. 60% after ded.
1. Go to www.umr.com and click on Outpatient 90% after ded. 60% after ded.
Find a Provider Emergency room 90% after ded.
Physician Visits and Ancillary Services
2. Select Medical to look up health Preventive care 100% 60% after ded.
providers Primary care (family
or general practitioner,
3. Scroll down and select internal medicine, 90% after ded. 60% after ded.
UnitedHealthcare Choice Plus pediatrician, OB/GYN)
Specialist visits 90% after ded. 60% after ded.
Urgent care 90% after ded. 60% after ded.
Lab services 90% after ded. 60% after ded.
X-ray/radiology 90% after ded. 60% after ded.
Chiropractic care 90% after ded. 60% after ded.
Physical, occupational,
and speech therapy 90% after ded. 60% after ded.
Durable medical 90% after ded. 60% after ded.
equipment
Mental Health and Substance Abuse
Inpatient 90% after ded. 60% after ded.
Outpatient 90% after ded. 60% after ded.
Prescription Drugs—Copayment Applies after the Annual Deductible is Satisied
Retail (30-day supply) Mail Order (90-day supply)
Generic $10 $10
Brand formulary $30 $75
Brand non-formulary $50 $150
Only covered through Annual deductible then
Specialty OptumRx Specialty Mail 25% up to $150 maximum
Order copayment
4
Benefits Enrollment
2016 Medical Benefits
HSA Plan
Annual Deductible In-Network Out-of-Network
Employee only $1,500 $10,000
Employee + spouse $2,750 $20,000
UMR Provider Search Employee + child(ren) $2,750 $20,000
To get the highest level of coverage Family $3,500 $20,000
from your plan, use “In-Network” Out-of-Pocket Limit (Includes Deductible)
participating health care providers. Employee only $2,450 $20,000
Receiving services from a participating Employee + spouse $4,400 $40,000
“In-Network” provider reduces your out- Employee + child(ren) $4,400 $40,000
of-pocket healthcare costs. To conirm Family $5,400 $40,000
if your provider is participating or to Lifetime maximum Unlimited
search for providers, just follow these Hospital
simple steps. Inpatient 90% after ded. 60% after ded.
1. Go to www.umr.com and click on Outpatient 90% after ded. 60% after ded.
Find a Provider Emergency room 90% after ded.
Physician Visits and Ancillary Services
2. Select Medical to look up health Preventive care 100% 60% after ded.
providers Primary care (family
or general practitioner,
3. Scroll down and select internal medicine, 90% after ded. 60% after ded.
UnitedHealthcare Choice Plus pediatrician, OB/GYN)
Specialist visits 90% after ded. 60% after ded.
Urgent care 90% after ded. 60% after ded.
Lab services 90% after ded. 60% after ded.
X-ray/radiology 90% after ded. 60% after ded.
Chiropractic care 90% after ded. 60% after ded.
Physical, occupational,
and speech therapy 90% after ded. 60% after ded.
Durable medical 90% after ded. 60% after ded.
equipment
Mental Health and Substance Abuse
Inpatient 90% after ded. 60% after ded.
Outpatient 90% after ded. 60% after ded.
Prescription Drugs—Copayment Applies after the Annual Deductible is Satisied
Retail (30-day supply) Mail Order (90-day supply)
Generic $10 $10
Brand formulary $30 $75
Brand non-formulary $50 $150
Only covered through Annual deductible then
Specialty OptumRx Specialty Mail 25% up to $150 maximum
Order copayment
4
Benefits Enrollment
