Page 11 - Burnham BG 2018-19 v4
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HEALTH BENEFITS: MEDICAL PLAN OPTIONS  HEALTH BENEFITS: MEDICAL PLAN OPTIONS




                                                     UnitedHealthcare                     UnitedHealthcare
                                                   Gold Select Plus 1000               Silver Select Plus 2000
                                                          PPO Plan                            HSA Plan
                                                In-Network       Non-Network         In-Network      Non-Network
                                                (Select Plus)                        (Select Plus)
                  Plan Provisions
                  Lifetime Maximum                        Unlimited                            Unlimited
                  Annual Deductible
                   Individual                     $1,000            $2,000             $2,000           $13,000
                   Family                         $2,000            $4,000             $2,700           $26,000
                  Coinsurance (Plan Pays)          80%               50%                80%              50%
                  Out-of-Pocket Maximum
                   Individual                     $6,000           $12,000             $6,500           $26,000
                   Family                         $12,000          $24,000             $13,000          $52,000
                  Medical Coverage
                  Physician Office Visit
                   PCP                           $25 Copay           50%                80%              50%
                   Specialist                    $50 Copay           50%                80%              50%

                  Telemedicine                Available through   Not Covered      Available through   Not Covered
                                              UHC Virtual Visit                    UHC Virtual Visit
                  Hospitalization
                   Inpatient                  $250 Copay, 80%  $250 Copay, 50%          80%              50%
                   Outpatient Surgery         $250 Copay, 80%  $250 Copay, 50%          80%              50%
                  Emergency Services                     $150 Copay                              80%
                                                      Waived if Admitted
                  Urgent Care                    $75 Copay           50%                80%              50%
                  Preventive Care                  100%          Not Covered        100% (No Ded)     Not Covered
                  Alternative Care
                  Chiropractic                   $25 Copay           50%                80%              50%
                                                      Max 24 Visits/Year                   Max 24 Visits/Year
                  Acupuncture                    $25 Copay           50%                80%              50%

                  Prescription Drugs
                   Retail Pharmacy                                                 Plan Ded Applies  Plan Ded Applies
                   – Supply Limit                 30 Days          30 Days             30 Days          30 Days
                   – Tier 1                      $15 Copay        $15 Copay           $20 Copay        $20 Copay
                   – Tier 2                      $35 Copay        $35 Copay           $50 Copay        $50 Copay
                   – Tier 3                      $70 Copay        $70 Copay          $100 Copay       $100 Copay
                   – Tier 4                    25%, Max $250    25%, Max $250      25%, Max $250     25%, Max $250
                   Mail Order Pharmacy
                   – Supply Limit                 90 Days            N/A               90 Days            N/A
                   – Tier 1                    $37.50 Copay      Not Covered         $50 Copay        Not Covered
                   – Tier 2                    $87.50 Copay      Not Covered         $125 Copay       Not Covered
                   – Tier 3                     $175 Copay       Not Covered         $250 Copay       Not Covered
                   – Tier 4                    25%, Max $625     Not Covered       25%, Max $625      Not Covered


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