Page 7 - 2018 Harbin Benefit Guide

Harbin Clinic

High Deductible Plan

Harbin Clinic and UHC In-Network Out-of-Network
Calendar Year Deductible
Embedded/Non-embedded Embedded Embedded
Individual $3,000 $6,000
Family $6,000 $12,000
Coinsurance Percentage 100% 50%
Out-of-Pocket Maximum
Embedded/Non-embedded Embedded Embedded
Individual $3,000 Unlimited
Family $6,000 Unlimited
Physician Ofice Visits
Primary Care 100% after deductible 50% after deductible
Specialist 100% after deductible 50% after deductible
Urgent Care 100% after deductible 50% after deductible
Wellness/Preventive 100% no deductible 50% after deductible
Hospital Services
Inpatient 100% after deductible 50% after deductible
Outpatient 100% after deductible 50% after deductible
Emergency Room 100% after deductible 100% after deductible
Prescription Drugs
Retail—34 Day
Generic 100% after deductible N/A
Preferred Brand 100% after deductible N/A
Non-Preferred Brand 100% after deductible N/A
Specialty 100% after deductible N/A
Retail—90 Day
Generic 100% after deductible N/A
Preferred Brand 100% after deductible N/A
Non-Preferred Brand 100% after deductible N/A
Specialty N/A N/A

2018 Contributions

Wellness Monthly Standard Monthly
Employee Only $108 $208
Employee and Spouse $328 $584
Employee and Child $428 $440
Employee and Children $408 $528
Employee and Family $492 $772

7