Page 11 - 2018 SLU Enrollment
P. 11
Saint Louis University
Medical/Prescription Drug Plan Details
UHC Plus Plan UHC QHDHP Plan
SLUCare and SSM UHC In-Network Out-of-Network SLUCare and SSM UHC In-Network Out-of-Network
Calendar Year Deductible Non-Embedded*
Individual $250 $750 $1,000 $1,500 $1,500 $3,000
Family $500 $1,500 $2,000 $3,000 $3,000 $6,000
Coinsurance 10% 20% 40% 0% 10% 40%
Out-of-Pocket Maximum (Includes Medical Deductibles and Copays) Non-Embedded
Individual $1,500 $1,750 $5,000 $1,500 $3,000 $6,000
Family $3,000 $3,500 $10,000 $3,000 $6,000 $12,000
Physician Ofice Visits
Primary Care $10 copay 20% after ded. 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Specialist Care $20 copay 20% after ded. 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Urgent Care
$50 copay $50 copay 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Hospital Services
Inpatient 10% after ded. 20% after ded. 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Emergency Room $100 copay $100 copay $100 copay 0% after ded. 10% after ded. 10% after ded.
Prescription Drugs—Express Scripts
Retail (34-Day Supply) Mail Order (90-Day Supply) Retail (34-Day Supply) Mail Order (90-Day Supply)
Tier 1 $10 $25 Medical deductible, then 10% coinsurance
Tier 2 $35 $87.50 Medical deductible, then 10% coinsurance
Tier 3 50% coinsurance 50% coinsurance Medical deductible, then 10% coinsurance
$50 min–$100 max $125 min–$250 max
Tier 4 20% to $150 Not covered Medical deductible, then 10% coinsurance
Select Preventive Priced according to the tier in which they fall Covered at 100%, no deductible
Medications
Out-of-Pocket Maximum (Includes Prescription Drug Copays and Coinsurance Costs)
Individual $1,000 Combined with medical
Family $2,000 Combined with medical
* ”Non-Embedded” means the entire deductible or out-of-pocket maximum could be borne by one family member.
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there is
a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.
Medical/Prescription Drug Contributions
2018 Pre-Tax Plan Payroll Deductions
Monthly Premium Bi-Weekly Premium
Coverage Type
Non-Wellness With Wellness Discount Non-Wellness With Wellness Discount
UHC Plus Plan
Employee $159.69 $109.69 $73.70 $50.63
Employee and Spouse $439.87 $364.87 $203.02 $168.40
Employee and Child(ren) $380.10 $330.10 $175.43 $152.35
Family $596.22 $521.22 $275.18 $240.56
UHC Qualiied High Deductible Health Plan
Employee $84.87 $34.87 $39.17 $16.09
Employee and Spouse $283.54 $208.54 $130.86 $96.25
Employee and Child(ren) $238.68 $188.68 $110.16 $87.08
Family $372.95 $297.95 $172.13 $137.52
UHC Plus Plan—Employees earning up to $37,740
Employee $50.00 $0.00 $23.08 $0.00
Employee and Spouse $330.18 $255.18 $152.39 $117.78
Employee and Child(ren) $270.41 $220.41 $124.80 $101.73
Family $486.53 $411.53 $224.55 $189.94
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Medical/Prescription Drug Plan Details
UHC Plus Plan UHC QHDHP Plan
SLUCare and SSM UHC In-Network Out-of-Network SLUCare and SSM UHC In-Network Out-of-Network
Calendar Year Deductible Non-Embedded*
Individual $250 $750 $1,000 $1,500 $1,500 $3,000
Family $500 $1,500 $2,000 $3,000 $3,000 $6,000
Coinsurance 10% 20% 40% 0% 10% 40%
Out-of-Pocket Maximum (Includes Medical Deductibles and Copays) Non-Embedded
Individual $1,500 $1,750 $5,000 $1,500 $3,000 $6,000
Family $3,000 $3,500 $10,000 $3,000 $6,000 $12,000
Physician Ofice Visits
Primary Care $10 copay 20% after ded. 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Specialist Care $20 copay 20% after ded. 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Urgent Care
$50 copay $50 copay 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Hospital Services
Inpatient 10% after ded. 20% after ded. 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Emergency Room $100 copay $100 copay $100 copay 0% after ded. 10% after ded. 10% after ded.
Prescription Drugs—Express Scripts
Retail (34-Day Supply) Mail Order (90-Day Supply) Retail (34-Day Supply) Mail Order (90-Day Supply)
Tier 1 $10 $25 Medical deductible, then 10% coinsurance
Tier 2 $35 $87.50 Medical deductible, then 10% coinsurance
Tier 3 50% coinsurance 50% coinsurance Medical deductible, then 10% coinsurance
$50 min–$100 max $125 min–$250 max
Tier 4 20% to $150 Not covered Medical deductible, then 10% coinsurance
Select Preventive Priced according to the tier in which they fall Covered at 100%, no deductible
Medications
Out-of-Pocket Maximum (Includes Prescription Drug Copays and Coinsurance Costs)
Individual $1,000 Combined with medical
Family $2,000 Combined with medical
* ”Non-Embedded” means the entire deductible or out-of-pocket maximum could be borne by one family member.
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there is
a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.
Medical/Prescription Drug Contributions
2018 Pre-Tax Plan Payroll Deductions
Monthly Premium Bi-Weekly Premium
Coverage Type
Non-Wellness With Wellness Discount Non-Wellness With Wellness Discount
UHC Plus Plan
Employee $159.69 $109.69 $73.70 $50.63
Employee and Spouse $439.87 $364.87 $203.02 $168.40
Employee and Child(ren) $380.10 $330.10 $175.43 $152.35
Family $596.22 $521.22 $275.18 $240.56
UHC Qualiied High Deductible Health Plan
Employee $84.87 $34.87 $39.17 $16.09
Employee and Spouse $283.54 $208.54 $130.86 $96.25
Employee and Child(ren) $238.68 $188.68 $110.16 $87.08
Family $372.95 $297.95 $172.13 $137.52
UHC Plus Plan—Employees earning up to $37,740
Employee $50.00 $0.00 $23.08 $0.00
Employee and Spouse $330.18 $255.18 $152.39 $117.78
Employee and Child(ren) $270.41 $220.41 $124.80 $101.73
Family $486.53 $411.53 $224.55 $189.94
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