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Open Enrollment

Medical

Medical coverage remains with UnitedHealthcare for the 2015 plan

year. Eligible employees will continue to have the choice between two
medical plans—the Traditional Plan and the High Deductible Health
Plan. Each plan utilizes the UnitedHealthcare Choice Plus network.

Please review the beneit details of your plan options before deciding
which plan is best for you.

UnitedHealthcare
UnitedHealthcare Qualiied High Deductible
Traditional PPO Health Plan—HSA

In-Network Out-of- In-Network Out-of-
Network Network
Lifetime Unlimited Unlimited
Maximum
Calendar Year Deductible
Embedded Non-Embedded
Individual $1,000 $2,000 $2,500 $5,000
Family $2,000 $4,000 $5,000 $10,000
Includes non-embedded
Includes embedded
Out-of-pocket deductibles, coinsurance, and deductibles, coinsurance, and
maximum copays prescription copays
Individual $3,500 $5,000 $4,000 $8,000
Family $7,000 $10,000 $8,000 $16,000
Physician Ofice Visits
Primary care $25 copay 50% after 20% after 50% after
deductible deductible deductible
Specialist $50 copay 50% after 20% after 50% after
deductible deductible deductible
Urgent care $75 copay 50% after 20% after 50% after
deductible deductible deductible
Preventive Care Services
To ind an In-Network provider or Covered at 50% after Covered at 50% after
hospital, please visit www.myuhc.com. 100% deductible 100% deductible
When asked to select a network, choose Hospital Services
50% after
20% after
UnitedHealthcare Choice Plus. Inpatient deductible 50% after 20% after deductible
deductible
deductible
Outpatient 20% after 50% after 20% after 50% after
deductible deductible deductible deductible
Emergency $200 copay $200 copay 20% after 20% after
Room deductible deductible

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