Page 6 - Pathway EE Guide OOS 06-17

BENEFITS

Medical Insurance

United Healthcare
Plan Name HDHP
Network Name Select Plus Non-Network
Health Benefits
Lifetime Maximum Benefit Unlimited

Deductible (Annual)
- Individual $3,000 $5,000
- Family $6,000 $10,000
Co-Insurance (Plan Pays) 90% 70%
Office Visit Copay
- Primary Care Physician Deductible, 10% Deductible, 30%
- Specialist Office Visit Deductible, 10% Deductible, 30%
- Virtual Visits Deductible, 10% N/A
Out-of-Pocket Maximum
- Individual $4,000 $6,000
- Family $8,000 $12,000

Hospitalization
- Inpatient Deductible, 10% Deductible, 30%
- Outpatient Surgery Deductible, 10% Deductible, 30%
Lab and X-Ray Deductible, 10% Deductible, 30%
Emergency Services Deductible, 10%
Urgent Care (Outside of Med Group) Deductible, 10% Deductible, 30%

Preventive Care No Charge Not Covered
Chiropractic Deductible, 10% Deductible, 30%
Max 24 Visits/Year
Pharmacy Benefits

Pharmacy Deductible Health Deductible Applies
Retail Pharmacy
- Generic Formulary / Tier 1 Deductible, $10 Copay Deductible, $10 Copay
- Brand Name Formulary / Tier 2 Deductible, $30 Copay Deductible, $30 Copay
- Non-Formulary / Tier 3 Deductible, $50 Copay Deductible, $50 Copay
- Supply Limit 30 Days 30 Days

Mail Order Pharmacy
- Generic Formulary / Tier 1 Deductible, $25 Copay Not Covered
- Brand Name Formulary / Tier 2 Deductible, $75 Copay Not Covered
- Non-Formulary / Tier 3 Deductible, $125 Copay Not Covered
- Supply Limit 90 Days N/A

Summary of Benefits and Coverage (SBC)
This guide is designed to help you understand the medical plan options offered to you by Pathway. Please refer to the SBC and
carrier contracts provided by United Healthcare for additional plan details.

6