Page 4 - TNJH 2019 Benefits Guide

Medical Insurance – United Healthcare HRA & HSA Plan Options

The chart below is a brief outline of the 2019 United Healthcare Choice Plus HRA and the United Healthcare Choice
Plus HSA medical plan options. Please refer to the United Healthcare Summary of Benefits for a complete listing of
all covered services.

2019 United Healthcare HRA Plan Option 2019 United Healthcare HSA Plan Option
Plan Provisions
In- Out-of- In- Out-of-
Network Network Network Network

TNJH Contribution to HRA (Individual/Family) $750/$1,500 N/A

Annual Deductible (Individual/Family) $2,250/$4,500 $4,000/$8,000 $2,000/$4,000 $3,000/$6,000

Out-of-Pocket Maximum (Includes Deductible) $5,000/$10,000 $8,000/$16,000 $3,000/$6,000 $6,000/$12,000

Lifetime Maximum Unlimited Unlimited

Preventive Care No Charge Not covered No Charge Not covered

Primary Physician 20%* 40%* 10%* 30%*
Office Visit

Specialist Office Visit 20%* 40%* 10%* 30%*

X-Ray and Lab No Charge 40%* 10%* 30%*

Advanced Imaging (MRI, MRA, CAT, etc.) 20%* 40%* 10%* 30%*

Inpatient Hospital Services 20%* 40%* 10%* 30%*

Outpatient Hospital Services 20%* 40%* 10%* 30%*

Urgent Care 20%* 40%* 10%* 30%*

Emergency Room Care 20%* 20%* 10%* 10%*

Prescription Drug Deductible N/A Medical plan deductible applies
Retail Prescription Drugs (30-day supply)

 Generic $10 copay $10 copay*
 Brand Preferred $30 copay Not covered $35 copay* Not covered
 Brand Non-preferred $50 copay $60 copay*

Mail Order Prescription Drugs (90-day supply)
 Generic $25 copay $25 copay*
 Brand Preferred $75 copay N/A $87.50 copay* N/A

 Brand Non-preferred $125 copay $150 copay*
*After deductible is met.

Your Benefits Guide 4
2019