Page 7 - Jones and Frank Benefits Enrollments Guide
P. 7
Medical Benefits
You have the option to select between two medical plan options for 2018. The Core and the Buy-
Up plan features are highlighted below:
UNITED HEALTHCARE DUAL OPTION MEDICAL PROGRAM
CORE PLAN OPTION BUY-UP PLAN OPTION
Choice Plus Choice Plus
AR-5L w/Rx 364 AR-3D w/Rx 0Z3
In-Network Member Pays In-Network Member Pays
Primary Care Physician Copay $35 $30
Specialist Office Visit Copay Deductible then 40% $60
Virtual Visits $10 $10
Preventive Care Visits 0% (Plan covers 100%) 0% (Plan covers 100%)
Emergency Room Services (waived if admitted) Deductible then 40% $500
Urgent Care Center Copay $125 $100
Inpatient Hospital & Professional Charges Deductible then 40% Deductible then 30%
Outpatient Facility & Physician Charges Deductible then 40% Deductible then 30%
Prescription Medication Copay:
Tier 1 $10 $20
Tier 2 $100 $65
Tier 3 $175 $100
Tier 4 $250 N/A
Mail Order 2.5 times retail copay 2.5 times retail copay
Individual Annual Deductible $ 5,000 $ 3,500
Individual Annual Out-of-Pocket Maximum $ 7,150 $ 6,850
Family Annual Deductible $ 10,000 $ 7,000
Family Annual Out-of-Pocket Maximum $ 14,300 $ 12,500
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