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P. 5
Electric Power Systems
Important Insurance
Definitions
UnitedHealthcare
UnitedHealthcare Qualiied High Deductible Embedded Deductible—meaning an
Traditional PPO
individual deductible or out-of-pocket
Health Plan—HSA
Out-of- Out-of- maximum can be satisied without the
In-Network Network In-Network Network full family deductible or out-of-pocket
Prescription Preventive Drugs By USPSTF maximum being satisied.
Drugs Covered 100%
Retail—Supply Non-Embedded Deductible—
Limit 31 Days 31 Days meaning no individual family
Tier 1 $10 copay $10 copay $10 copay $10 copay member’s deductible or out-of-pocket
after after
deductible deductible maximum is satisied until the full
Tier 2 $35 copay $35 copay $35 copay $35 copay family deductible or out-of-pocket
after after maximum is satisied. One member
deductible deductible of the family can meet the full family
Tier 3 $70 copay $70 copay $60 copay $60 copay
after after deductible or out-of pocket maximum
deductible deductible or it can be a combination.
Mail Order—
Supply Limit 90 Days Not covered 90 Days Not covered Coinsurance—the members’ portion
Tier 1 $25 copay Not covered $25 copay Not covered of cost share once the embedded or
after non-embedded deductible is satisied.
deductible
Tier 2 $87.50 copay Not covered $87.50 Not covered
copay after
deductible
Tier 3 $175 copay Not covered $150 Not covered
copay after
deductible
When you elect the High Deductible Health Plan—HSA, you also receive a
company-paid Critical Illness plan provided through Allstate. This plan is
intended to serve as a cushion against unexpected costs which may arise
during your time on the plan. If diagnosed with any of the below illnesses,
Allstate will pay you the amount shown on a tax-free basis. To receive the
beneit, you must ile a claim and submit medical documentation. Please
contact HR with questions.
Invasive Cancer $5,000
Heart Attack $5,000
Major Organ Transplant $5,000
End Stage Renal Failure $5,000
Stroke $5,000
Carcinoma in Situ $1,250
Coronary Artery By-Pass Surgery $1,250
5
Important Insurance
Definitions
UnitedHealthcare
UnitedHealthcare Qualiied High Deductible Embedded Deductible—meaning an
Traditional PPO
individual deductible or out-of-pocket
Health Plan—HSA
Out-of- Out-of- maximum can be satisied without the
In-Network Network In-Network Network full family deductible or out-of-pocket
Prescription Preventive Drugs By USPSTF maximum being satisied.
Drugs Covered 100%
Retail—Supply Non-Embedded Deductible—
Limit 31 Days 31 Days meaning no individual family
Tier 1 $10 copay $10 copay $10 copay $10 copay member’s deductible or out-of-pocket
after after
deductible deductible maximum is satisied until the full
Tier 2 $35 copay $35 copay $35 copay $35 copay family deductible or out-of-pocket
after after maximum is satisied. One member
deductible deductible of the family can meet the full family
Tier 3 $70 copay $70 copay $60 copay $60 copay
after after deductible or out-of pocket maximum
deductible deductible or it can be a combination.
Mail Order—
Supply Limit 90 Days Not covered 90 Days Not covered Coinsurance—the members’ portion
Tier 1 $25 copay Not covered $25 copay Not covered of cost share once the embedded or
after non-embedded deductible is satisied.
deductible
Tier 2 $87.50 copay Not covered $87.50 Not covered
copay after
deductible
Tier 3 $175 copay Not covered $150 Not covered
copay after
deductible
When you elect the High Deductible Health Plan—HSA, you also receive a
company-paid Critical Illness plan provided through Allstate. This plan is
intended to serve as a cushion against unexpected costs which may arise
during your time on the plan. If diagnosed with any of the below illnesses,
Allstate will pay you the amount shown on a tax-free basis. To receive the
beneit, you must ile a claim and submit medical documentation. Please
contact HR with questions.
Invasive Cancer $5,000
Heart Attack $5,000
Major Organ Transplant $5,000
End Stage Renal Failure $5,000
Stroke $5,000
Carcinoma in Situ $1,250
Coronary Artery By-Pass Surgery $1,250
5
