Page 4 - 2016 Enrollment

Open Enrollment

Medical Plan

UHC High Deductible Health Plan (HDHP)
In-Network Out-of-Network
Calendar Year Deductible
Employee $1,300 $2,600
Family $2,600 $5,200
Coinsurance
90% 60%
Out-of-Pocket Maximum (includes deductible)
Employee $2,000 $4,000
Family $4,000 $8,000
Preventive Care
Preventive care 100% no deductible 60% after deductible
Physician Ofice Visits
Primary care 90% after deductible 60% after deductible
Specialist 90% after deductible 60% after deductible
Hospital
Inpatient 90% after deductible 60% after deductible
Outpatient 90% after deductible 60% after deductible
Emergency Room
90% after deductible 90% after deductible
Urgent Care
90% after deductible 60% after deductible
Mental Health/Substance Abuse
Inpatient 90% after deductible 60% after deductible
Outpatient 90% after deductible 60% after deductible
2016 Semi-Monthly

Contributions Retail (30-day Supply) In-Network Out-of-Network

Your 2016 semi-monthly contributions Tier 1 $10 after deductible $10 after deductible
for medical coverage are shown below. Tier 2 $30 after deductible $30 after deductible
Tier 3 $50 after deductible $50 after deductible
Medical Semi-Monthly Contributions Mail Order (90-day Supply)
Employee only $27.50 Tier 1 $20 after deductible Not Covered
Employee + 1 $60.00 Tier 2 $60 after deductible Not Covered
Family $80.00 Tier 3 $100 after deductible Not Covered

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