Page 7 - iFly Employee Benefit Guide 2019

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
Life me Maximum Unlimited Unlimited

Deduc ble (Annual)
‐ Individual $1,000 $2,000 $3,000 $6,000
‐ Family $2,000 $6,000 $6,000 $18,000
Employer HSA Contribu on N/A $500
Co‐Insurance (Plan Pays) 80% 50% 90% 50%
Office Visit Copay
‐ Primary Care Physician $30 Copay Deduc ble, 50% Deduc ble, 10% Deduc ble, 50%
‐ Specialist Office Visit $50 Copay Deduc ble, 50% Deduc ble, 10% Deduc ble, 50%
‐ Telemedicine $15 Copay Not Covered Deduc ble, 10% Not Covered
Out‐of‐Pocket Maximum
‐ Individual $5,000 $10,000 $6,000 $12,500
‐ Family $10,000 $30,000 $12,000 $37,500

Hospitaliza on
‐ Inpa ent Deduc ble, 20% Deduc ble, 50% Deduc ble, 10% Deduc ble, 50%
‐ Outpa ent Deduc ble, 20% Deduc ble, 50% Deduc ble, 10% Deduc ble, 50%
Emergency Services $300 Copay, 20% Deduc ble, 10%
Urgent Care $75 Copay Deduc ble, 50% Deduc ble, 10% Deduc ble, 50%

Preven ve Care No Charge Deduc ble, 50% No Charge Deduc ble, 50%
Chiroprac c $50 Copay Deduc ble, 550% Deduc ble, 10% Deduc ble, 50%
20 Visits/Year 20 Visits/Year
Pharmacy Benefits

Pharmacy Deduc ble
‐ Individual $0 $0 Plan Deduc ble Plan Deduc ble
‐ Family $0 $0 Plan Deduc ble Plan Deduc ble
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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