Page 11 - 2016 Open Enrollment
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Dentsu Aegis Network (DAN)
Medical Plan Highlights
In addiion to the Health Savings Plan, we ofer three PPO plans featuring in and out-of-network coverage. The
following table summarizes the main features of the medical plan opions and changes as of January 1, 2016. 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 HSA Plan ****
Out-of-
Out-of-
Out-of-
Out-of-
Plan Feature* In-Network Network In-Network Network In-Network Network In-Network Network
Employee Contribuions Per Pay Period
Employee $52.97 $88.51 $121.27 $28.02
Employee + $119.47 $204.93 $301.45 $74.91
Spouse
Employee + $106.52 $183.55 $267.70 $66.38
Child(ren)
Family $199.50 $341.55 $502.22 $124.85
Deducible
Individual $1,000 $2,000 $500 $1,000 $350 $700 $2,000 $4,000
Family $2,000 $4,000 $1,000 $2,000 $700 $1,400 $4,000 $8,000
HSA Account Funding
Individual/ N/A N/A N/A $500/$1,000
Family
Out-of-Pocket Max**
Individual $4,000 $8,000 $4,000 $8,000 $3,000 $6,000 $4,000 $12,000
Family $8,000 $16,000 $8,000 $16,000 $6,000 $12,000 $6,850 $24,000
Plan 80% 60% 90% 80% 100% 80% 80% 60%
Coinsurance
Oice Visit Copay
Prevenive Free Ded. and Free Ded. and Free Ded. and Free Ded. and
Coin. Coin. Coin. Coin.
Virtual Visits $15 Not Covered $15 Not Covered $15 Not Covered Ded. and Not Covered
Coin.
Primary Care $30 Ded. and $30 Ded. and $30 Ded. and Ded. and Ded. and
Coin. Coin. Coin. Coin. Coin.
Specialist $50 Ded. and $50 Ded. and $50 Ded. and Ded. and Ded. and
Coin. Coin. Coin. Coin. Coin.
Hospital Facility
Inpaient Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and
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
Coin. Coin. Coin. Coin. Coin. Coin. Coin. Coin.
Emergency $250 $250 $250 Ded. and Coin.
Room Copay
Purple text indicates a beneit change.
11
Medical Plan Highlights
In addiion to the Health Savings Plan, we ofer three PPO plans featuring in and out-of-network coverage. The
following table summarizes the main features of the medical plan opions and changes as of January 1, 2016. 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 HSA Plan ****
Out-of-
Out-of-
Out-of-
Out-of-
Plan Feature* In-Network Network In-Network Network In-Network Network In-Network Network
Employee Contribuions Per Pay Period
Employee $52.97 $88.51 $121.27 $28.02
Employee + $119.47 $204.93 $301.45 $74.91
Spouse
Employee + $106.52 $183.55 $267.70 $66.38
Child(ren)
Family $199.50 $341.55 $502.22 $124.85
Deducible
Individual $1,000 $2,000 $500 $1,000 $350 $700 $2,000 $4,000
Family $2,000 $4,000 $1,000 $2,000 $700 $1,400 $4,000 $8,000
HSA Account Funding
Individual/ N/A N/A N/A $500/$1,000
Family
Out-of-Pocket Max**
Individual $4,000 $8,000 $4,000 $8,000 $3,000 $6,000 $4,000 $12,000
Family $8,000 $16,000 $8,000 $16,000 $6,000 $12,000 $6,850 $24,000
Plan 80% 60% 90% 80% 100% 80% 80% 60%
Coinsurance
Oice Visit Copay
Prevenive Free Ded. and Free Ded. and Free Ded. and Free Ded. and
Coin. Coin. Coin. Coin.
Virtual Visits $15 Not Covered $15 Not Covered $15 Not Covered Ded. and Not Covered
Coin.
Primary Care $30 Ded. and $30 Ded. and $30 Ded. and Ded. and Ded. and
Coin. Coin. Coin. Coin. Coin.
Specialist $50 Ded. and $50 Ded. and $50 Ded. and Ded. and Ded. and
Coin. Coin. Coin. Coin. Coin.
Hospital Facility
Inpaient Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and Ded. and
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
Coin. Coin. Coin. Coin. Coin. Coin. Coin. Coin.
Emergency $250 $250 $250 Ded. and Coin.
Room Copay
Purple text indicates a beneit change.
11
