Page 10 - 2018 SLU New Hire Guide
P. 10
Medical/Prescription Drug Plan Details
UHC Plus Plan UHC QHDHP Plan
SLUCare and SLUCare and
SSM UHC In-Network Out-of-Network SSM UHC In-Network Out-of-Network
Calendar Year Deductible Non-Embedded*
Individual $250 $750 $1,000 $1,500 $1,500 $3,000
Family $500 $1,500 $2,000 $3,000 $3,000 $6,000
Coinsurance 10% 20% 40% 0% 10% 40%
Out-of-Pocket Maximum (includes medical deductibles and copays) Non-Embedded
Individual $1,500 $1,750 $5,000 $1,500 $3,000 $6,000
Family $3,000 $3,500 $10,000 $3,000 $6,000 $12,000
Physician Ofice Visits
Primary Care $10 copay 20% after ded. 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Specialist Care $20 copay 20% after ded. 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Urgent Care
$50 copay $50 copay 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Hospital Services
Inpatient 10% after ded. 20% after ded. 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Emergency $100 copay $100 copay $100 copay 0% after ded. 10% after ded. 10% after ded.
room
Prescription Drugs—Express Scripts
Retail (34-day supply) Mail Order (90-day supply) Retail (34-day supply) Mail Order (90-day supply)
Tier 1 $10 $25 Medical deductible, then 10% coinsurance
Tier 2 $35 $87.50 Medical deductible, then 10% coinsurance
Tier 3 50% coinsurance 50% coinsurance Medical deductible, then 10% coinsurance
$50 min-$100 max $125 min-$250 max
Tier 4 20% to $150 Not covered Medical deductible, then 10% coinsurance
Select preventive Priced according to the tier in which they fall Covered at 100%, no deductible
medications
Out-of-Pocket Maximum (includes prescription drug copays and coinsurance costs)
Individual $1,000 Combined with medical
Family $2,000 Combined with medical
* “Non-Embedded” means the entire deductible or out-of-pocket maximum could be borne by one family member.
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there
is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.
10 2018 New Hire Guide
UHC Plus Plan UHC QHDHP Plan
SLUCare and SLUCare and
SSM UHC In-Network Out-of-Network SSM UHC In-Network Out-of-Network
Calendar Year Deductible Non-Embedded*
Individual $250 $750 $1,000 $1,500 $1,500 $3,000
Family $500 $1,500 $2,000 $3,000 $3,000 $6,000
Coinsurance 10% 20% 40% 0% 10% 40%
Out-of-Pocket Maximum (includes medical deductibles and copays) Non-Embedded
Individual $1,500 $1,750 $5,000 $1,500 $3,000 $6,000
Family $3,000 $3,500 $10,000 $3,000 $6,000 $12,000
Physician Ofice Visits
Primary Care $10 copay 20% after ded. 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Specialist Care $20 copay 20% after ded. 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Urgent Care
$50 copay $50 copay 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Hospital Services
Inpatient 10% after ded. 20% after ded. 40% after ded. 0% after ded. 10% after ded. 40% after ded.
Emergency $100 copay $100 copay $100 copay 0% after ded. 10% after ded. 10% after ded.
room
Prescription Drugs—Express Scripts
Retail (34-day supply) Mail Order (90-day supply) Retail (34-day supply) Mail Order (90-day supply)
Tier 1 $10 $25 Medical deductible, then 10% coinsurance
Tier 2 $35 $87.50 Medical deductible, then 10% coinsurance
Tier 3 50% coinsurance 50% coinsurance Medical deductible, then 10% coinsurance
$50 min-$100 max $125 min-$250 max
Tier 4 20% to $150 Not covered Medical deductible, then 10% coinsurance
Select preventive Priced according to the tier in which they fall Covered at 100%, no deductible
medications
Out-of-Pocket Maximum (includes prescription drug copays and coinsurance costs)
Individual $1,000 Combined with medical
Family $2,000 Combined with medical
* “Non-Embedded” means the entire deductible or out-of-pocket maximum could be borne by one family member.
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there
is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.
10 2018 New Hire Guide
