Page 6 - 2018 Harbin Benefit Guide
P. 6
Traditional PPO Plan
UHC In-Network when
Harbin Clinic Harbin Provider Available In-Network Out-of-Network
Calendar Year Deductible
Embedded/Non- Embedded Embedded Embedded Embedded
embedded
Individual $1,750 $1,750 $1,750 $3,500
Family $3,500 $3,500 $3,500 $7,000
Coinsurance Percentage 80% 80% 80% 60%
Out-of-Pocket Maximum
Embedded/Non- Embedded Embedded Embedded Embedded
embedded
Individual $5,500 $5,500 $5,500 Unlimited
Family $11,000 $11,000 $11,000 Unlimited
Physician Ofice Visits
Primary Care $30 copay 80% after deductible $45 copay 60% after deductible
Specialist $50 copay 80% after deductible $65 copay 60% after deductible
Urgent Care $30 copay $75 copay $75 copay 60% after deductible
Wellness/Preventive 100% no deductible 100% no deductible 100% no deductible 60% after deductible
Hospital Services
Inpatient 80% after deductible 80% after deductible 80% after deductible 60% after deductible
Outpatient 80% after deductible 80% after deductible 80% after deductible 60% after deductible
Emergency Room Not applicable Not applicable $200 copay $200 copay
Mental Health
Inpatient Not applicable Not applicable 80% after deductible 60% after deductible
Outpatient 80% after deductible 80% after deductible 80% after deductible 60% after deductible
Ofice Visits $30 copay 80% after deductible $45 copay 60% after deductible
Prescription Drugs
Retail—34 day
Generic $20 copay Not applicable $25 copay Not covered
Preferred Brand 20% to a $75 max then Not applicable 25% to a $75 max then Not covered
100% 100%
Non-Preferred Brand 30% to a $125 max then Not applicable 50% to a $125 max then Not covered
100% 100%
Specialty 5% to a $350 max then Not applicable 5% to a $350 max then Not covered
100% 100%
Retail—90 day
Generic $60 copay Not applicable Not available Not covered
Preferred Brand 20% to a $200 max then Not applicable Not available Not covered
100%
Non-Preferred Brand 30% to a $350 max then Not applicable Not available Not covered
100%
Specialty Not available Not applicable Not available Not covered
2018 Contributions
Medical Wellness Monthly Standard Monthly
Employee Only $166 $326
Employee and Spouse $470 $836
Employee and Child $470 $630
Employee and Children $561 $720
Employee and Family $649 $1,016
6 2018 Benefits Guide
UHC In-Network when
Harbin Clinic Harbin Provider Available In-Network Out-of-Network
Calendar Year Deductible
Embedded/Non- Embedded Embedded Embedded Embedded
embedded
Individual $1,750 $1,750 $1,750 $3,500
Family $3,500 $3,500 $3,500 $7,000
Coinsurance Percentage 80% 80% 80% 60%
Out-of-Pocket Maximum
Embedded/Non- Embedded Embedded Embedded Embedded
embedded
Individual $5,500 $5,500 $5,500 Unlimited
Family $11,000 $11,000 $11,000 Unlimited
Physician Ofice Visits
Primary Care $30 copay 80% after deductible $45 copay 60% after deductible
Specialist $50 copay 80% after deductible $65 copay 60% after deductible
Urgent Care $30 copay $75 copay $75 copay 60% after deductible
Wellness/Preventive 100% no deductible 100% no deductible 100% no deductible 60% after deductible
Hospital Services
Inpatient 80% after deductible 80% after deductible 80% after deductible 60% after deductible
Outpatient 80% after deductible 80% after deductible 80% after deductible 60% after deductible
Emergency Room Not applicable Not applicable $200 copay $200 copay
Mental Health
Inpatient Not applicable Not applicable 80% after deductible 60% after deductible
Outpatient 80% after deductible 80% after deductible 80% after deductible 60% after deductible
Ofice Visits $30 copay 80% after deductible $45 copay 60% after deductible
Prescription Drugs
Retail—34 day
Generic $20 copay Not applicable $25 copay Not covered
Preferred Brand 20% to a $75 max then Not applicable 25% to a $75 max then Not covered
100% 100%
Non-Preferred Brand 30% to a $125 max then Not applicable 50% to a $125 max then Not covered
100% 100%
Specialty 5% to a $350 max then Not applicable 5% to a $350 max then Not covered
100% 100%
Retail—90 day
Generic $60 copay Not applicable Not available Not covered
Preferred Brand 20% to a $200 max then Not applicable Not available Not covered
100%
Non-Preferred Brand 30% to a $350 max then Not applicable Not available Not covered
100%
Specialty Not available Not applicable Not available Not covered
2018 Contributions
Medical Wellness Monthly Standard Monthly
Employee Only $166 $326
Employee and Spouse $470 $836
Employee and Child $470 $630
Employee and Children $561 $720
Employee and Family $649 $1,016
6 2018 Benefits Guide
