Page 5 - 2016 Enrollment

American Food & Vending

UnitedHealthcare (UHC) Major Medical Plan

PPO CDHP
Beneit In-Network Out-of- In-Network Out-of-
Network Network
Deductibles and Maximums
Individual $1,500 $4,500 $2,600 $8,000
Family $4,500 $13,500 $5,200 $16,000
Out-of-Pocket calendar year maximum (includes deductible, copays,
and coinsurance)
Individual $4,500 $13,500 $6,550 $16,000
Family $13,200 $40,500 $13,100 $32,000
Lifetime beneit Unlimited Unlimited Unlimited
maximum
Covered Services
Ofice visits
Primary physician 100% after 80% after
$35 copay deductible
Specialist 100% after 50% after 80% after 50% after
$60 copay deductible deductible deductible
Preventive care 100% no 100% no
copay copay/no
deductible
Emergency medical care
Emergency room 100% after 100% after 80% after
$250 copay $250 copay deductible
Urgent care 100% after 50% after 80% after 50% after
$50 copay deductible deductible deductible
Ambulance 70% after 50% after 80% after
deductible deductible deductible
Hospital services
Inpatient services 70% after 50% after 80% after 50% after
Outpatient services deductible deductible deductible deductible
Prescription Beneits
Retail (up to 31 days)
In-network $20/$40/$60 80% after deductible
Out-of-network $20/$40/$60
Mail (up to 90 days)
In-network $40/$80/$120 80% after deductible
Out-of-network Not covered Not covered

UHC Plan Weekly Contribution Rates
PPO CDHP *
Employee $64.35 $48.51
Employee + spouse $157.10 $132.96
Employee + child(ren) $151.20 $128.26
Family $170.23 $143.36

* Employees who enroll in the CDHP will be provided with a contribution by AFV based on
the tier of coverage you elect, to help fund your HSA account.

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