Page 10 - iFLY Benefit Guide 01-20

Medical Plan highlights

United Healthcare United Healthcare
Plan Name PPO Buy-Up HSA PPO Base

Network Name Choice Plus Non-Network Choice Plus Non-Network
Plan Differences
Team Member Payroll Cost $$ $
Out-of-Pocket Costs $ $$
Health Savings Account 
- iFLY Contribution 
- Team Member Contribution 

Cost Sharing Contribution, Copay, Contribution, Copay,
Deductible, Coinsurance Deductible, 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 $1,000 $2,000 $3,000 $6,000
- Family $2,000 $6,000 $6,000 $18,000
Out-of-Pocket Maximum
- Individual $5,000 $10,000 $6,000 $12,500
- Family $10,000 $30,000 $12,000 $37,000
iFLY’s HSA Contribution N/A $500
Coinsurance (Plan Pays) 80% 50% 90% 50%

Office Visit Copay
- Preventive Care No Charge Deductible, 50% No Charge Deductible, 50%
- Primary Care Physician $30 Copay Deductible, 50% Deductible, 10% Deductible, 50%
- Specialist $50 Copay Deductible, 50% Deductible, 10% Deductible, 50%
- Urgent Care $75 Copay Deductible, 50% Deductible, 10% Deductible, 50%
- Telemedicine $15 Copay N/A Deductible, 10% N/A
Hospitalization
- Inpatient Deductible, 20% Deductible, 50% Deductible, 10% Deductible, 50%
- Outpatient Surgery Deductible, 20% Deductible, 50% Deductible, 10% Deductible, 50%
Lab and X-Ray
- Diagnostic No Charge Deductible, 50% Deductible, 10% Deductible, 50%
- Complex No Charge Deductible, 50% Deductible, 10% Deductible, 50%
Emergency Services $300 Copay, 20% Deductible, 10%

Chiropractic $50 Copay Deductible, 50% Deductible, 10% Deductible, 50%
Max 20 Visits/Year Max 20 Visits/Year

10 Team Member Benefits