Page 10 - 2015 Enrollment Guide

10

UHC Medical and Prescription Drug Plan Options

Traditional Choice Plus PPO Plan Consumer HSA Choice Plus Plan
In-Network Out-of-Network In-Network Out-of-Network
Plan Year Deductible: Plan Year is July 1, 2015 through June 30, 2016
Individual $500 $1,000 $1,500 $1,500
Family $1,000 $2,000 $3,000 $3,000
Out-of-Pocket Maximum Includes Deductibles
Individual $3,500 $7,000 $3,500 $7,000
Family $7,000 $14,000 $7,000 $14,000
Wellness/Preventive
100% covered 30% after deductible 100% covered 30% after deductible
Physician Ofice Visits
Primary care 20% after deductible 30% after deductible 20% after deductible 30% after deductible
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
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)

Notes: Medications found on OptumRx’s Expanded Preventive Drug List are covered at 100 percent and must be illed through mail order as
noted on page 9.
You are required to obtain certain drugs, including certain specialty drugs, from a designated OptumRx specialty pharmacy. Certain drugs
may have a pre-notiication requirement. If you use a non-network pharmacy, you are responsible for any amount over the allowed
amount.
Medications found on the HCR Preventive Drug list are covered at 100 percent and are not required to be illed through mail order.
Both preventive drugs lists as well as the Specialty and Prior Authorization Drug lists can be found on the ADP/WFN portal as you enroll
for beneits.
Optimas OE Solutions Holdings, LLC