Page 9 - Parsons and Parsons Corp ODD EE Guide 1 1 17_FINAL 11.1.16

Benefits For Your Health

MEDICAL INSURANCE

UnitedHealthcare Choice Plus UnitedHealthcare
Plan Name High Deductible Health Plan (HDHP) Choice Plus PPO

Parsons Corp Parsons Corp
Eligible Employee Classes
Parsons Corp ODD
Network Name UHC ChoicePlus UHC ChoicePlus
Health Benefits Network Non-Network Network Non-Network

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual / Family $1,500 / $3,000 $3,000 / $6,000 $250 / $750 $750 / $1,750
Co-Insurance (Plan Pays) 80% 60% 80% 60%
Office Visit Copay
- Primary Care Physician 80% after deductible 60% after deductible $30 60% after deductible
- Specialist Office Visit 80% after deductible 60% after deductible $30 60% after deductible

Out-of-Pocket Maximum
- Individual / Family $3,500 / $7,000 $7,000 / $14,000 $6,000 / $12,000 $6,000 / $12,000

Hospitalization
- Inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
- Outpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible

Lab and X-Ray 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Emergency Services 80% after deductible $200 (copay waived if admitted)
Urgent Care 80% after deductible 60% after deductible $50 60% after deductible

Preventive Care Covered 100% 60% after deductible Covered 100% 60% after deductible
Chiropractic 80% after deductible 60% after deductible $30 60% after deductible
24 Visits/Year 24 Visits/Year
Pharmacy Benefits

Pharmacy Deductible 80% after deductible Not Covered None Not Covered
Retail Pharmacy
- (Generic/Brand/Non-Formulary) 80% after deductible Not Covered $10 / $40 / $80 Not Covered

Retail Preventive (ACA) $10 / $40 / $80 Not Covered $10 / $40 / $80 Not Covered
- (Generic/Brand/Non-Formulary) Eligible expenses Not Covered Eligible expenses Not Covered
covered 100% covered 100%
- Supply Limit 30 days N/A 30 days N/A
Mail Order Pharmacy
- (Generic/Brand/Non-Formulary) 80% after deductible Not Covered $20 / $80 / $160 Not Covered

Mail Order Preventive
- (Generic/Brand/Non-Formulary) $20 / $80 / $160 Not Covered $20 / $80 / $160 Not Covered

- Supply Limit 90 Days N/A 90 Days N/A

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