Page 7 - Charles E Thomas EE Guide 12-19

BENEFITS

Medical Insurance

United Healthcare United Healthcare
Plan Name Select Plus BILS PPO Select Plus Core AHV1 PPO
Network Name Select Plus Non-Network Select Plus Non-Network
Health Benefits
Lifetime Maximum Unlimited Unlimited

Deductible (Annual)
- Individual $250 $500 $250 $500
- Family $500 $1,000 $500 $1000
Out-of-Pocket Maximum
- Individual $3,500 $7,000 $2,250 $4,500
- Family $7,000 $14,000 $4,500 $9,000

Co-Insurance (Plan Pays) 70% 50% 90% 60%
Office Visit Copay
- Preventive Care No Charge Not Covered No Charge Not Covered
- Primary Care Physician $20 Copay Deductible, 50% $20 Copay Deductible, 40%
- Specialist Office Visit $30 Copay Deductible, 50% $20 Copay Deductible, 40%
- Urgent Care $125 Copay Deductible, 50% $50 Copay Deductible, 40%
- Virtual Visits $20 Copay N/A $20 Copay N/A

Hospitalization
- Inpatient Deductible, Deductible, Deductible, Deductible,
$500 Copay, 30% $500 Copay, 50% 20% 40%
- Outpatient Deductible, 30% Deductible, 50% Deductible, 20% Deductible, 40%
Lab and X-Ray
- Diagnostic No Charge Deductible, 50% No Charge Deductible, 40%
- Complex Deductible, 30% Deductible, 50% Deductible, 20% Deductible, 40%
Emergency Services $250 Copay $100
Chiropractic $20 Copay Deductible, 50% $20 Copay Deductible, 40%
24 Visits/Year 24 Visits/Year
Pharmacy Benefits

Pharmacy Deductible
- Individual $0 $0 $0 $0
- Family $0 $0 $0 $0
Retail Pharmacy
- Tier 1 $15 Copay $15 Copay $15 Copay $15 Copay
- Tier 2 $35 Copay $35 Copay $35 Copay $35 Copay
- Tier 3 $50 Copay $50 Copay $50 Copay $50 Copay
- Supply Limit 30 Days 30 Days 30 Days 30 Days

Mail Order Pharmacy
- Tier 1 $30 Copay Not Covered $30 Copay Not Covered
- Tier 2 $70 Copay Not Covered $70 Copay Not Covered
- Tier 3 $100 Copay Not Covered $100 Copay Not Covered
- Supply Limit 90 Days N/A 90 Days N/A

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