Page 8 - Guide

2017 Medical Benefits

PPO HDHP
In-Network Out-of-Network In-Network Out-of-Network
Annual deductible $750 each person $1,500 each person $1,500 individual (see below)
$1,500 family $3,000 family $3,000 family (see below)
Prescription drugs not subject to deductible Prescription drugs subject to deductible
Annual out-of-pocket maximum $2,750 each person $5,500 each person $2,975 individual $5,950 individual
$5,500 family $11,000 family $5,950 family $11,900 family
Includes deductibles; prescription drugs do not Includes deductibles; prescription drugs count
count toward medical maximum toward medical maximum
Lifetime maximum Unlimited Unlimited Unlimited Unlimited
Preventive Care (For example: routine physicals, x-rays and lab tests, immunizations, routine mammogram and gynecological exam,
sigmoidoscopy, and hearing screenings)
100% no deductible 60% no deductible 100% no deductible 60% no deductible
Physician Services/Outpatient Care
Physician office visit (including 80% after deductible 60% after deductible 80% after deductible 60% after deductible
virtual visits)
Outpatient surgery (performed 80% after deductible 60% after deductible 80% after deductible 60% after deductible
in physician office, hospital, or
freestanding facility)
Diagnostic tests 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Chiropractic care 80% after deductible 80% after deductible 80% after deductible 80% after deductible
Emergency Medical Care
Emergency room ($75 penalty 80% after deductible Covered at 80% after deductible Covered at
for non-emergency use) in-network level in-network level
X-rays and lab tests 80% after deductible Covered at 80% after deductible Covered at
in-network level In-network level
Ambulance services 80% after deductible Covered at 80% after deductible Covered at
in-network level in-network level
Inpatient Hospital Care
Physician/surgical services 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Semi-private room and board 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Maternity care 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Mental Health and Substance Abuse
Inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Additional Services
Physical, occupational, and 80% after deductible 80% after deductible 80% after deductible 80% after deductible
speech
Home healthcare, extended care 80% after deductible 60% after deductible 80% after deductible 60% after deductible
facility
Hospice; private duty nursing; 80% after deductible 80% after deductible 80% after deductible 80% after deductible
durable medical equipment;
prosthetic devices

Important Deductible and Out-of-Pocket Maximum Notice for HDHP Plan Participants
The individual deductible does not apply to employees’ with dependent coverage in the HDHP plan. For example, if you
incurred $2,000 in medical expenses, the plan will not pay until you, or other members of your family, have
accumulated medical expenses in excess of $3,000. This applies to out-of-pocket maximums as well.

Hussmann

8 Corporation