Page 8 - Burnham Benefits Guide 2017

MEDICAL INSURANCE

Summary of Kaiser Permanente UnitedHealthcare
Benefits and Platinum 0/15 Signature 20-40/70%
Coverage (SBC): Plan Features HMO Plan HMO Plan
Health insurance UnitedHealthcare
issuers and group Network Kaiser Permanente SignatureValue (HMO)
health plans are Lifetime Maximum Unlimited Unlimited
required to provide Annual Deductible
you with an easy-to- Individual None None
understand summary Family None None
about your health Coinsurance (Plan Pays) 100% 100%
plan’s benefits and
coverage, referred to as Physician Office Visit $15 Copay $20 Copay
a Summary of Benefits PCP $40 Copay $40 Copay
and Coverage (SBC). Specialist
This Employee Benefit Out-of-Pocket Maximum
Guide is designed to Individual $4,000 $3,000
help you compare the Family $8,000 $6,000
plan options offered by Hospitalization
Burnham. Please refer Inpatient $290/Day, Max 5 Days 70%
to the SBC and carrier Outpatient Surgery $290 Copay 70%
contracts for additional Emergency Services $150 Copay $200 Copay
plan details. Waived if Admitted Waived if Admitted
Urgent Care $15 Copay $20 Copay
Preventive Care 100% 100%
Chiropractic Not Covered $15 Copay
Max 20 Visits/Year

Acupuncture $15 Copay $10 Copay
Prescription Drugs
Retail Pharmacy
– Supply Limit 30 Days 30 Days
– Generic $5 Copay Tier 1: $15 Copay
– Brand Name Formulary $15 Copay Tier 2: $35 Copay
– Brand Name Non-Formulary N/A Tier 3: $50 Copay
Tier 4: 25% Max $250
Mail Order Pharmacy
– Supply Limit 100 Days 90 Days
– Generic $10 Copay Tier 1: $30 Copay
– Brand Name Formulary $30 Copay Tier 2: $70 Copay
– Brand Name Non-Formulary N/A Tier 3: $100 Copay
Tier 4: 25% Max $500

FINDING A MEDICAL PROVIDER:
• Kaiser Permanente: Login to www.kaiserpermanente.org or call (800) 464-4000
• UnitedHealthcare HMO: Login to www.myuhc.com or call (800) 624-8822. HMO
members should refer to the “UnitedHealthcare SignatureValue (HMO)” network
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