Page 12 - 2015 Enrollment Guide
P. 12
2015 Employee
Beneits Program
Medical Benefits Comparison
Beneits UnitedHealthcare POS UnitedHealthcare HSA UnitedHealthcare Kaiser HMO
Preferred Non-Preferred Preferred Non-Preferred HMO
Calendar Year HSA Fund Amount
Individual N/A $500 * N/A N/A
Family N/A $1,000 * N/A N/A
Health fund N/A Any unused funds are N/A N/A
maximum rolled over each year
Calendar Year Deductible
Individual $500 $1,000 $1,500 $3,000 N/A N/A
Family $1,500 $3,000 $3,000 $6,000 N/A
Calendar Year Out-of-Pocket Maximum (Includes Deductibles)
Individual $2,500 $5,000 $3,500 $7,000 $1,500 $1,500
Family $7,500 $15,000 $9,000 $18,000 $3,000 $3,000
Ofice Visit
Primary care $25 copay 40% * 20% * 40% * $25 copay $25 copay
Specialty care $40 copay 40% * 20% * 40% * $40 copay $25 copay
Prenatal care $40 copay for initial 40% * 20% * 40% * $25 copay for $25 copay for
visit, then no charge initial visit, then initial visit,
no charge then no charge
Lab and x-ray 20% 40% * 20% * 40% * No Charge No charge
(including complex)
Urgent care $50 copay 40% * 20% * 40% * $50 copay $25 copay
$100 copay (waived 20% * 20% * $100 copay $100 copay
Emergency room if admit) (waived if admit) (waived if
admitted)
Emergency use of 20% * 20% * 20% * 40% * No charge $50 per trip
ambulance
Inpatient hospital 20% * 40% * 20% * 40% * $350 copay per $500 copay
care admit per admission
20% * 40% * 20% * 40% * $100 copay per $25 copay per
Outpatient surgery surgery procedure
Spinal manipulation/ $40 copay (up to 20 40% * (up to 20% * 40% * $15 copay (up to Not covered
chiropractic visits per year) 20 visits per 20 visits/year)
year)
Durable medical 20% 40% * 20% * 40% * 20% No charge
equipment
Prescription Drugs
Retail—30 Day Supply
Generic $10 Preferred $10 $10
copay plus
50% excess 20%* 40%*
charges
Brand $25 $20 $20
Non-formulary $50 $35 N/A
Mail Order 90 Day Supply 90 Day Supply 90 Day Supply 100 day supply
Generic $20 Not Covered 20%* Not Covered $20 $20
Brand $50 $40 $40
Non-formulary $100 $70 N/A
* Subject to calendar year deductible.
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Beneits Program
Medical Benefits Comparison
Beneits UnitedHealthcare POS UnitedHealthcare HSA UnitedHealthcare Kaiser HMO
Preferred Non-Preferred Preferred Non-Preferred HMO
Calendar Year HSA Fund Amount
Individual N/A $500 * N/A N/A
Family N/A $1,000 * N/A N/A
Health fund N/A Any unused funds are N/A N/A
maximum rolled over each year
Calendar Year Deductible
Individual $500 $1,000 $1,500 $3,000 N/A N/A
Family $1,500 $3,000 $3,000 $6,000 N/A
Calendar Year Out-of-Pocket Maximum (Includes Deductibles)
Individual $2,500 $5,000 $3,500 $7,000 $1,500 $1,500
Family $7,500 $15,000 $9,000 $18,000 $3,000 $3,000
Ofice Visit
Primary care $25 copay 40% * 20% * 40% * $25 copay $25 copay
Specialty care $40 copay 40% * 20% * 40% * $40 copay $25 copay
Prenatal care $40 copay for initial 40% * 20% * 40% * $25 copay for $25 copay for
visit, then no charge initial visit, then initial visit,
no charge then no charge
Lab and x-ray 20% 40% * 20% * 40% * No Charge No charge
(including complex)
Urgent care $50 copay 40% * 20% * 40% * $50 copay $25 copay
$100 copay (waived 20% * 20% * $100 copay $100 copay
Emergency room if admit) (waived if admit) (waived if
admitted)
Emergency use of 20% * 20% * 20% * 40% * No charge $50 per trip
ambulance
Inpatient hospital 20% * 40% * 20% * 40% * $350 copay per $500 copay
care admit per admission
20% * 40% * 20% * 40% * $100 copay per $25 copay per
Outpatient surgery surgery procedure
Spinal manipulation/ $40 copay (up to 20 40% * (up to 20% * 40% * $15 copay (up to Not covered
chiropractic visits per year) 20 visits per 20 visits/year)
year)
Durable medical 20% 40% * 20% * 40% * 20% No charge
equipment
Prescription Drugs
Retail—30 Day Supply
Generic $10 Preferred $10 $10
copay plus
50% excess 20%* 40%*
charges
Brand $25 $20 $20
Non-formulary $50 $35 N/A
Mail Order 90 Day Supply 90 Day Supply 90 Day Supply 100 day supply
Generic $20 Not Covered 20%* Not Covered $20 $20
Brand $50 $40 $40
Non-formulary $100 $70 N/A
* Subject to calendar year deductible.
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