Page 10 - 2015 DAN Benefits Guide
P. 10
Open
Enrollment
Medical Plan Highlights
In addiion to the Health Savings Plan, we ofer three PPO plans featuring in and out-of-network coverage. We also
ofer an HMO as a ith opion for California employees. The following table summarizes the main features of the
medical plan opions and changes as of January 1, 2015. For a more detailed comparison of the medical plans visit
DAN beneitsPLUS website (where you can also access a link to UHC’s pre-enrollment site, Healthcare Lane, and more
comprehensive medical plan summaries).
Standard Plan Enhanced Plan Premium Plan Health Savings Plan **** HMO (CA
Only)
Plan In-Network Out-of- In-Network Out-of- In-Network Out-of- In-Network Out-of- HMO
Feature* Network Network Network Network Network
Employee Contribuions Per Pay Period
Employee $49.50 $81.95 $110.24 $26.68 $54.29
Employee + $111.65 $189.75 $274.04 $71.34 $145.04
Spouse
Employee + $99.55 $169.95 $243.36 $63.22 $106.26
Child(ren)
Family $186.45 $316.25 $456.56 $118.90 $169.79
Deducible
Individual $1,000 $2,000 $500 $1,000 $250 $500 $2,000 $4,000 $1,000
Family $2,000 $4,000 $1,000 $2,000 $500 $1,000 $4,000 $8,000 $2,000
HSA Account Funding
Individual/ N/A N/A N/A $500/$1,000 N/A
Family
Out-of-Pocket Max**
Individual $4,000 $8,000 $3,000 $6,000 $3,000 $6,000 $6,000 $12,000 $3,000
Family $8,000 $16,000 $6,000 $12,000 $6,000 $12,000 $12,000 $24,000 $6,000
Plan 80% 60% 90% 80% 100% 80% 80% 60% 80%
Coinsurance
Oice Visit Copay
Prevenive Free Ded. and Free Ded. and Free Ded. and Free Ded. and Free
Coin . Coin . Coin . Coin .
Primary Care $30 Ded. and $30 Ded. and $30 Ded. and Ded. and Ded. and $20 per visit
Coin . Coin . Coin . Coin . Coin .
Specialist $50 Ded. and $50 Ded. and $50 Ded. and Ded. and Ded. and $20 per visit
Coin . Coin . Coin . Coin . Coin .
Hospital Facility
Inpaient Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and
Coin . Coin . Coin . Coin . Coin . Coin . Coin . Coin . Coin .
Outpaient Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and
Coin . Coin . Coin . Coin . Coin . Coin . Coin . Coin . Coin .
Emergency $250 $250 $250 Ded. and Coin. Ded. and
Room Copay Coin .
10
Enrollment
Medical Plan Highlights
In addiion to the Health Savings Plan, we ofer three PPO plans featuring in and out-of-network coverage. We also
ofer an HMO as a ith opion for California employees. The following table summarizes the main features of the
medical plan opions and changes as of January 1, 2015. For a more detailed comparison of the medical plans visit
DAN beneitsPLUS website (where you can also access a link to UHC’s pre-enrollment site, Healthcare Lane, and more
comprehensive medical plan summaries).
Standard Plan Enhanced Plan Premium Plan Health Savings Plan **** HMO (CA
Only)
Plan In-Network Out-of- In-Network Out-of- In-Network Out-of- In-Network Out-of- HMO
Feature* Network Network Network Network Network
Employee Contribuions Per Pay Period
Employee $49.50 $81.95 $110.24 $26.68 $54.29
Employee + $111.65 $189.75 $274.04 $71.34 $145.04
Spouse
Employee + $99.55 $169.95 $243.36 $63.22 $106.26
Child(ren)
Family $186.45 $316.25 $456.56 $118.90 $169.79
Deducible
Individual $1,000 $2,000 $500 $1,000 $250 $500 $2,000 $4,000 $1,000
Family $2,000 $4,000 $1,000 $2,000 $500 $1,000 $4,000 $8,000 $2,000
HSA Account Funding
Individual/ N/A N/A N/A $500/$1,000 N/A
Family
Out-of-Pocket Max**
Individual $4,000 $8,000 $3,000 $6,000 $3,000 $6,000 $6,000 $12,000 $3,000
Family $8,000 $16,000 $6,000 $12,000 $6,000 $12,000 $12,000 $24,000 $6,000
Plan 80% 60% 90% 80% 100% 80% 80% 60% 80%
Coinsurance
Oice Visit Copay
Prevenive Free Ded. and Free Ded. and Free Ded. and Free Ded. and Free
Coin . Coin . Coin . Coin .
Primary Care $30 Ded. and $30 Ded. and $30 Ded. and Ded. and Ded. and $20 per visit
Coin . Coin . Coin . Coin . Coin .
Specialist $50 Ded. and $50 Ded. and $50 Ded. and Ded. and Ded. and $20 per visit
Coin . Coin . Coin . Coin . Coin .
Hospital Facility
Inpaient Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and
Coin . Coin . Coin . Coin . Coin . Coin . Coin . Coin . Coin .
Outpaient Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and
Coin . Coin . Coin . Coin . Coin . Coin . Coin . Coin . Coin .
Emergency $250 $250 $250 Ded. and Coin. Ded. and
Room Copay Coin .
10
