Page 5 - 2016 Enrollment

American Food & Vending

UnitedHealthcare (UHC)

Major Medical Plan

UHC ACA
Beneit In-Network Out-of-Network
Deductibles and Maximums
Individual $4,000 $8,000
Family $8,000 $16,000
Out-of-Pocket calendar year maximum (includes deductible, copays,
and coinsurance)
Individual $6,000 $12,000
Family $12,000 $24,000
Lifetime beneit maximum Unlimited
Covered Services
Ofice visits
Primary physician 80% after deductible
Specialist 80% after deductible 50% after deductible
Preventive care 100% no copay
Emergency medical care
Emergency room 80% after deductible 80% after deductible
Urgent care 80% after deductible 50% after deductible
Ambulance 80% after deductible 80% after deductible
Hospital services
Inpatient services 80% after deductible 50% after deductible
Outpatient services
Prescription Beneits
Retail (up to 31 days)
In-network 80% after deductible
Out-of-network 80% after deductible
Mail (up to 90 days)
In-network 80% after deductible
Out-of-network Not covered

UHC Plan Weekly Contribution Rates
Employee * $28.50
Employee + child(ren) $245.17

* If you earn below $10.00 an hour, please contact Human Resources for your weekly
contribution amount.

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