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2016 Benefits Enrollment

UHC Medical and Prescription Drug Plan Options
Consumer HSA Choice Plus Traditional Choice Plus PPO Plan
In-Network Out-of-Network In-Network Out-of-Network
Plan Year Deductible
Individual $2,000 $4,000 $1,000 $2,000
Family $4,000 $8,000 $2,000 $4,000
Out-of-Pocket Maximum Includes Deductibles
Individual $3,500 $7,000 $3,500 $7,000
Family $6,850 $14,000 $7,000 $14,000
Wellness/Preventive
100% covered 30% after deductible 100% covered 30% after deductible
Physician Ofice Visits
Primary care (includes 20% after deductible 30% after deductible 20% after deductible 30% after deductible
virtual visits)
Specialist 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Urgent Care
20% after deductible 30% after deductible 20% after deductible 30% after deductible
Hospital Services
Inpatient 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Outpatient 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Emergency room 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Mental Health and Substance Abuse
Inpatient 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Outpatient 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Ofice visits 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Care
Skilled nursing care 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Home healthcare 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Hospice care 20% after deductible 30% after deductible 20% after deductible 30% after deductible
Durable medical 20% after deductible 30% after deductible 20% after deductible 30% after deductible
equipment
Chiropractic Care
(Up to 20 visits per 20% after deductible 30% after deductible 20% after deductible 30% after deductible
calendar year)
Prescription Drugs*
Preventive drugs 100% 30% after deductible 100% 30% after deductible
Retail—supply Limit 20% after deductible 30% after deductible 20% after deductible 30% after deductible
(31-day supply)
Mail order—supply 20% after deductible 30% after deductible 20% after deductible 30% after deductible
limit (90-day supply)

* For more prescription drug information, please see page 7.

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