Page 5 - 2017 Benefits Enrollment
P. 5
Lanter Delivery Systems, Inc.
Medical Plan Options
Option 1—PPO Plan Option 2—HSA Plan
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $1,750 $4,500 $3,000 $7,800
Family $3,500 $9,000 $6,000 $15,600
Out-of-Pocket Maximum (includes deductible)
Individual $6,500 $10,000 $6,550 $13,100
Family $13,000 $20,000 $13,100 $26,200
Hospital Services
Inpatient Ded then 80% Ded then 50% Ded then 80% Ded then 50%
Outpatient Ded then 80% Ded then 50% Ded then 80% Ded then 50%
Emergency Room $300 copay Ded then 80%
Ofice Visits
Preventive Care 100% covered Ded then 50% 100% covered Ded then 50%
Primary Care $35 copay Ded then 50% Ded then 80% Ded then 50%
Specialist $70 copay Ded then 50% Ded then 80% Ded then 50%
Virtual Visit $25 copay Ded then 50% Ded then 80% Ded then 50%
Chiropractic Care (20 visit max) $35 copay Ded then 50% Ded then 80% Ded then 50%
Urgent Care $100 copay Ded then 50% Ded then 80% Ded then 50%
Prescription Drugs
Retail—Supply Limit 30 Days 30 Days
Tier 1 $15 copay Copay plus Ded then 80%** Copay plus
Tier 2 $40 copay difference* Ded then 80%** difference*
Tier 3 $75 copay Ded then 80%**
Mail Order—Supply Limit 90 days 90 days
Tier 1 $37.50 copay Copay plus Ded then 80%** Copay plus
Tier 2 $100 copay difference* Ded then 80%** difference*
Tier 3 $187.50 copay Ded then 80%**
This is a summary of your beneit coverage. Full coverage details are available in the policy or certiicate of coverage.
* If you purchase a Prescription Drug from a Non-Network Pharmacy, you are responsible for any difference between the Non-Network Pharmacy
charges and the amount UHC would have paid for the same drug at a Network Pharmacy.
** Preventive medications will be covered at 100% on the HSA Plan. They are not subject to a deductible or coinsurance. Refer to the
UnitedHealthcare Preventive Drug List on myuhc.com.
Premium Per Pay Period
Option 1—PPO Plan Option 2—HSA Plan
Employee (EE) $28.07 $17.91
Employee and Spouse $77.28 $53.32
Employee and Child(ren) $58.95 $34.29
Family $118.49 $95.15
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Medical Plan Options
Option 1—PPO Plan Option 2—HSA Plan
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $1,750 $4,500 $3,000 $7,800
Family $3,500 $9,000 $6,000 $15,600
Out-of-Pocket Maximum (includes deductible)
Individual $6,500 $10,000 $6,550 $13,100
Family $13,000 $20,000 $13,100 $26,200
Hospital Services
Inpatient Ded then 80% Ded then 50% Ded then 80% Ded then 50%
Outpatient Ded then 80% Ded then 50% Ded then 80% Ded then 50%
Emergency Room $300 copay Ded then 80%
Ofice Visits
Preventive Care 100% covered Ded then 50% 100% covered Ded then 50%
Primary Care $35 copay Ded then 50% Ded then 80% Ded then 50%
Specialist $70 copay Ded then 50% Ded then 80% Ded then 50%
Virtual Visit $25 copay Ded then 50% Ded then 80% Ded then 50%
Chiropractic Care (20 visit max) $35 copay Ded then 50% Ded then 80% Ded then 50%
Urgent Care $100 copay Ded then 50% Ded then 80% Ded then 50%
Prescription Drugs
Retail—Supply Limit 30 Days 30 Days
Tier 1 $15 copay Copay plus Ded then 80%** Copay plus
Tier 2 $40 copay difference* Ded then 80%** difference*
Tier 3 $75 copay Ded then 80%**
Mail Order—Supply Limit 90 days 90 days
Tier 1 $37.50 copay Copay plus Ded then 80%** Copay plus
Tier 2 $100 copay difference* Ded then 80%** difference*
Tier 3 $187.50 copay Ded then 80%**
This is a summary of your beneit coverage. Full coverage details are available in the policy or certiicate of coverage.
* If you purchase a Prescription Drug from a Non-Network Pharmacy, you are responsible for any difference between the Non-Network Pharmacy
charges and the amount UHC would have paid for the same drug at a Network Pharmacy.
** Preventive medications will be covered at 100% on the HSA Plan. They are not subject to a deductible or coinsurance. Refer to the
UnitedHealthcare Preventive Drug List on myuhc.com.
Premium Per Pay Period
Option 1—PPO Plan Option 2—HSA Plan
Employee (EE) $28.07 $17.91
Employee and Spouse $77.28 $53.32
Employee and Child(ren) $58.95 $34.29
Family $118.49 $95.15
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