Page 7 - Ifly Benefit Guide 2018 FINAL

Benefits

Medical Insurance

United Healthcare United Healthcare
Plan Name Medical Buy-Up Plan - TX OAMC Medical Base Plan - TX OAMC
PPO 1000 80/50 Rx 2A HSA 3000 90/50

Network Name Network Non-Network Network Non-Network
Health Benefits
Lifetime Maximum Unlimited Unlimited

Deductible (Annual)
- Individual $1,000 $2,000 $3,000 $6,000
- Family $2,000 $6,000 $6,000 $18,000
Co-Insurance (Plan Pays) 80% 50% 90% 50%
Office Visit Copay
- Primary Care Physician $30 Copay Deductible, 50% Deductible, 10% Deductible, 50%
- Specialist Office Visit $50 Copay Deductible, 50% Deductible, 10% Deductible, 50%

Out-of-Pocket Maximum
- Individual $5,000 $10,000 $6,000 $12,500
- Family $10,000 $30,000 $12,000 $37,500
Hospitalization
- Inpatient Deductible, 20% Deductible, 50% Deductible, 10% Deductible, 50%
- Outpatient Deductible, 20% Deductible, 50% Deductible, 10% Deductible, 50%
Emergency Services $300 Copay, 20% Deductible, 10%
Urgent Care $75 Copay Deductible, 50% Deductible, 10% Deductible, 50%

Preventive Care No Charge Deductible, 50% No Charge Deductible, 50%
Chiropractic $50 Copay Deductible, 550% Deductible, 10% Deductible, 50%
20 Visits/Year 20 Visits/Year
Pharmacy Benefits

Pharmacy Deductible
- Individual $0 $0 Plan Deductible Plan Deductible
- Family $0 $0 Plan Deductible Plan Deductible
Retail Pharmacy (30 Day Supply)
- Generic Formulary $15 Copay $15 Copay + 30% $10 Copay $10 Copay + 30%
- Brand Name Formulary $50 Copay $50 Copay + 30% $35 Copay $35 Copay + 30%
- Non-Formulary $90 Copay $90 Copay + 30% $70 Copay $70 Copay + 30%
- Specialty (Formulary/Non Formulary) $150 $150 + 30% $150 $150 + 30%

Mail Order Pharmacy (90 Day Supply)
- Generic Formulary $37.50 Copay Not Covered $25 Copay Not Covered
- Brand Name Formulary $125 Copay Not Covered $87.50 Copay Not Covered
- Non-Formulary $225 Copay Not Covered $175 Copay Not Covered
- Specialty (Formulary/Non Formulary) Not Covered Not Covered Not Covered Not Covered

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