Page 7 - Petroleum Mktg EE Guide 12-19
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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             $1,000
         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%                  80%               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 Copay
         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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