Page 11 - TCM EE Guide 2019 v2 FINAL

Medical Plan highlights

United United
Healthcare Healthcare
Plan Name PPO HSA PPO
UHC UHC
Network Name Select Plus Non-Network Select Plus Non-Network
Plan Differences
Employee Premiums $$$ $$
Employee Cost Sharing Contribution, Deductible, Contribution, Deductible,
Copay, Coinsurance Copay, Coinsurance

Network 
- Network Size  
- In-Network Benefits  
- Non-Network Benefits  

Access to Providers Managed by You Managed by You
Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited
Calendar Year Deductible
- Individual $750 $1,500 $2,700 $3,700
- Family $1,500 $3,000 $5,400 $7,400

Out-of-Pocket Maximum
- Individual $2,500 $5,000 $3,700 $7,400
- Family $5,000 $10,000 $7,400 $14,800
- Copays Included Yes Yes Yes Yes

Coinsurance (You Pay) 20% 40% 0% 20%

Office Visit Copay
- Preventive Care No Charge Not Covered No Charge Not Covered
- Primary Care Physician $35 Copay Deductible, 40% Deductible, 0% Deductible, 20%
- Specialist $35 Copay Deductible, 40% Deductible, 0% Deductible, 20%
- Urgent Care (Med Group) $125 Copay Deductible, 40% Deductible, 0% Deductible, 20%
- Urgent Care (Other) $125 Copay Deductible, 40% Deductible, 0% Deductible, 20%
- Telemedicine $25 Copay N/A Deductible, 0% N/A

Hospitalization
- Inpatient Deductible, 20% Deductible, 40% Deductible, 0% Deductible, 20%
- Outpatient Surgery Deductible, 20% Deductible, 40% Deductible, 0% Deductible, 20%

Lab and X-Ray
- Diagnostic No Charge Deductible, 40% Deductible, 0% Deductible, 20%
- Complex Deductible, 20% Deductible, 40% Deductible, 0% Deductible, 20%

Emergency Services $250 Copay Deductible, 0%

Mental Health
- Inpatient Deductible, 20% Deductible, 40% Deductible, 0% Deductible, 20%
- Outpatient $35 Copay Deductible, 40% Deductible, 0% Deductible, 20%

Employee Benefits 11