Page 8 - Guide

2017 BENEFITS ENROLLMENT

UnitedHealthcare—Options PPO Network
Effective February 1, 2017 to January 31, 2018
In-Network Out-of-Network
Lifetime maximum Unlimited
Deductible (Employee Responsibility)
Individual $750 $1,500
Family $1,500 $3,000
Coinsurance 80% 60%
Out-of-Pocket Maximum (excludes deductibles)
Individual $2,750 $5,500
Family $5,500 $11,000
Physician ofice visits
Primary care $20 copay, then 80% 60% after deductible
Specialist $20 copay, then 80% 60% after deductible
Emergency Room
$100 copay, then 80% $100 copay, then 80%
Preventive
Routine physical exams
Routine immunizations
Well child care 100%, no deductible 60% after deductible
Annual well woman
Mammograms
In-Network Prescription Drug Beneits
Retail (30 day supply) Mail (90 day supply)
Tier 1 (generics) $10 copay $25 copay
Tier 2 (brands/preferred $30 copay $70 copay
brands)
Tier 3 (brands/non- $45 copay $112.50 copay
preferred brands)

The following are the contributions which will be effective on February 1,
2017.

Weekly Employee Premium—Medical Plan
Base Contribution
Employee $39.37
Employee/spouse $93.36
Employee/children $80.02
Employee/family $142.26

8 MOTOMART