Page 10 - 2019 CommScope
P. 10
2019 UHC Medical Plan Options
Health & Investment Health & Investment
Plan A Plan B PPO Medical Plan
Plan Design (IN: In-network, OON: Out-of-network)
HSA CommScope Contribution $500 $500 N/A
Medical Deductible (single/family) IN $3,000/$6,000 $1,500/$3,000 $750/$1,500
Medical Deductible (single/family) OON $6,000/$12,000 $3,600/$7,800 $1,500/$3,000
Out-of-Pocket Max IN (all services & Rx) $6,550/$13,100 $3,750/$7,500 $3,500/$7,000
Out-of-Pocket Max OON (all services & Rx) $13,100/$26,200 $7,500/$15,000 $7,000/$14,000
Plan Provided Co-insurance (IN) 70% 80% 80%
Plan Provided Co-insurance (OON) 60% 60% 60%
Coverage In-Network
100% plan
100% plan
100% plan
Preventive Care provided coverage provided coverage provided coverage
70% plan provided 80% plan provided
Primary Care/Specialist co-insurance after co-insurance after $25/$40 member copay
deductible is met deductible is met
80% plan provided
Emergency Room Same as above Same as above co-insurance after
deductible is met
Hospital per Admission Same as above Same as above Same as above
Prescription Drugs In-Network
70% plan provided 80% plan provided
Retail Tier 1/Tier 2/Tier 3/Specialty co-insurance after co-insurance after $11/$32/$55/$115
member copay
deductible is met deductible is met
$22/$75/$125
Mail Order Tier 1/Tier 2/Tier 3 Same as above Same as above member copay
HSA-eligible;
HSA-eligible;
Traditional PPO
Other Notes Traditional deductible* True family deductible* Traditional deductible*
* Traditional deductible means an individual on a family contract is only responsible for meeting the single deductible
and out-of-pocket maximums with their individual claims, not the full family amount. A true family deductible means an
individual can be responsible for all or any remaining portion of the family deductible and out-of-pocket maximum. Once
the family deductible or out-of-pocket maximum is satisied, claims for the entire family are covered at 100%.
10 ANNUAL ENROLLMENT GUIDE BENEFITS 2019
Health & Investment Health & Investment
Plan A Plan B PPO Medical Plan
Plan Design (IN: In-network, OON: Out-of-network)
HSA CommScope Contribution $500 $500 N/A
Medical Deductible (single/family) IN $3,000/$6,000 $1,500/$3,000 $750/$1,500
Medical Deductible (single/family) OON $6,000/$12,000 $3,600/$7,800 $1,500/$3,000
Out-of-Pocket Max IN (all services & Rx) $6,550/$13,100 $3,750/$7,500 $3,500/$7,000
Out-of-Pocket Max OON (all services & Rx) $13,100/$26,200 $7,500/$15,000 $7,000/$14,000
Plan Provided Co-insurance (IN) 70% 80% 80%
Plan Provided Co-insurance (OON) 60% 60% 60%
Coverage In-Network
100% plan
100% plan
100% plan
Preventive Care provided coverage provided coverage provided coverage
70% plan provided 80% plan provided
Primary Care/Specialist co-insurance after co-insurance after $25/$40 member copay
deductible is met deductible is met
80% plan provided
Emergency Room Same as above Same as above co-insurance after
deductible is met
Hospital per Admission Same as above Same as above Same as above
Prescription Drugs In-Network
70% plan provided 80% plan provided
Retail Tier 1/Tier 2/Tier 3/Specialty co-insurance after co-insurance after $11/$32/$55/$115
member copay
deductible is met deductible is met
$22/$75/$125
Mail Order Tier 1/Tier 2/Tier 3 Same as above Same as above member copay
HSA-eligible;
HSA-eligible;
Traditional PPO
Other Notes Traditional deductible* True family deductible* Traditional deductible*
* Traditional deductible means an individual on a family contract is only responsible for meeting the single deductible
and out-of-pocket maximums with their individual claims, not the full family amount. A true family deductible means an
individual can be responsible for all or any remaining portion of the family deductible and out-of-pocket maximum. Once
the family deductible or out-of-pocket maximum is satisied, claims for the entire family are covered at 100%.
10 ANNUAL ENROLLMENT GUIDE BENEFITS 2019
