Page 5 - 2018 OCLC Recruitment Guide

MEDICAL BENEFITS AT-A-GLANCE

PPO Plan—UHC “Choice Plus” EPO—UHC “Select EPO”
In-Network Out-of-Network In-Network Only
Calendar Year Deductible
Individual/Family $350/$700 $700/$1,400 None
Out-of-Pocket Maximum
Individual/Family $1,850/$3,700 $3,700/$7,400 $1,850/$3,700
Service Type
Preventive/Wellness 100% covered Not covered 100% covered
Office Visits $20 copay 30% after deductible $20 copay
Urgent Care 10% after deductible 30% after deductible $35 copay
Emergency Room 10% after deductible; 10% after deductible; $150 copay;
copay and deductible copay and deductible copay waived if admitted
waived if admitted waived if admitted
Prescription Drugs
Annual Out-of-Pocket
Maximum $2,000 per covered person; $6,000 per family
Retail—Up to a 31-Day Supply
Tier 1 Up to $12 copay
Tier 2 30% coinsurance ($25 minimum/up to $65 per prescription)
Tier 3 50% coinsurance ($65 minimum/up to $130 per prescription)
Mail Order—Up to a 90-Day Supply
Tier 1 $30 copay
Tier 2 30% coinsurance ($62 minimum/up to $163 per prescription)
Tier 3 50% coinsurance ($162 minimum/up to $325 per prescription)

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