Page 8 - P&A Group Benefits Enrollments Guide

Medical & Prescription Drug Option

Plan for 2017-2018
CORE PLAN BUY UP PLAN
Benefit Highlights
United Healthcare HMO AJ-PM United Healthcare HMO AJ-
Rx/2V H.S.A. PW Rx/2V
In-Network Member Pays In-Network Member Pays
Physician Services
Primary Care Physician Office
Deductible then $30 $30
Visit
Specialist Office Visit Deductible then $60 $60
Preventive Medical Services:
Routine preventive screenings,
0% (Plan covers 100%) 0% (Plan covers 100%)
well-baby/child, and women's
preventive care
Hospital/Emergency
Emergency Room Deductible then $250 $350
Urgent Care Deductible then $100 $75
Inpatient Hospitalization Services Deductible then $500 Deductible then 30%
Outpatient Facility & Physician
Deductible then $300 Deductible then 30%
Charges
Prescription Drugs 2.5 x cost for mail order, up to a 90-day supply of prescriptions.
Tier 1 Deductible then $10 $10
Tier 2 Deductible then $35 $35
Tier 3 Deductible then $60 $60
Tier 4 N/A N/A
Deductibles and coinsurance maximums are accumulated based on benefit
Deductibles and Maximums
plan year, January 1 to December 31.
Individual Annual Deductible $4,000 $2,500
Individual Annual Coinsurance
$2,500 $3,500
Maximum
Individual Annual Out-of-Pocket $6,500 $6,000
Maximum

Family Annual Deductible $8,000 $5,000
Family Annual Coinsurance
$5,000 $7,000
Maximum
Family Annual Out-of-Pocket
$13,000 $12,000
Maximum

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