Page 6 - Hussmann- Chino Union OE Guide 2015 Plan Year

Annual
Enrollment

2015 Medical Benefits
United Healthcare Choice Plus Plan In-Network Out-of-Network
Effective January 1, 2015
Annual deductible—what you pay each calendar year Each person $0 $500
for covered services before the plan starts to pay Family $0 $1,500

Annual out-of-pocket maximum—the limit on what Each person $1,250 $2,500
you pay each calendar year for covered services; Family $2,500 $5,000
excludes prescription drug copays, coinsurance for
chiropractic care and dental charges due to accident
Lifetime Maximum Unlimited
Preventive Care
Certain preventive health services based upon age, gender and other $0 Not Covered
factors are available with no cost-sharing, as long as they are received in-
network (for example: wellness physicals, well child care, x-rays, lab tests,
immunizations, routine mammogram, gynecological exam, sigmoidoscopy,
vision, and hearing screenings.)
Physician Care
Physician ofice visit primary or specialist 80% no deductible 60% of eligible expenses after deductible
PCP referral for specialist care Not Required
Well-child care $0 Not Covered
Annual routine physical exam includes adult immunizations and routine lab $0 Not Covered
and x-rays
Other Physician Services (e.g., surgery, anesthesia) 80% no deductible 60% of eligible expenses after deductible
Annual Routine Gynecological Exam Includes Pap smear, mammography, $0 Not Covered
and related lab fees
Family Planning/Maternity Care
Physician ofice visits pre- and post-natal 80% no deductible 60% of eligible expenses after deductible
Other physician services 80% no deductible 60% of eligible expenses after deductible
Inpatient hospital services 80% no deductible 60% of eligible expenses after deductible
Prior Notiication Required
Hospital Care—Facility Charges
Inpatient services 80% no deductible 60% of eligible expenses after deductible
Prior Notiication Required
Emergency room—medical emergency $75 penalty for non-emergency use 80% no deductible Covered as a network beneit
Notiication required if results in inpatient stay
Outpatient services 80% no deductible 60% of eligible expenses after deductible
Other Healthcare Services
X-ray and lab 80% no deductible 60% of eligible expenses after deductible
Chiropractic care up to 20 visits per calendar year 80% no deductible 60% of eligible expenses after deductible
Second surgical opinion 80% no deductible 60% of eligible expenses after deductible
Durable medical equipment 80% no deductible 60% of eligible expenses after deductible
Physical, occupational and speech therapy 80% no deductible 60% of eligible expenses after deductible
Mental Health and Substance Abuse
Outpatient 80% no deductible 60% of eligible expenses after deductible
Inpatient 80% no deductible 60% of eligible expenses after deductible
Prior notiication required

This document provides only the highlights of the medical options; speciic coverage details and limitations are found in the plan documents and
summary plan descriptions. In the event of conlict between this information and relevant plan documents or summary plan descriptions, the plan
documents or summary plan descriptions will govern. Only medically necessary services are covered. Note that services from non-network providers
are subject to reasonable and customary (R&C) limits. Charges in excess of R&C are not covered.

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