Page 9 - Burnham Benefits Guide 2017

MEDICAL INSURANCE

UnitedHealthcare UnitedHealthcare
Select Plus 20/750/20% Select Plus 2000/80%
Plan Features PPO Plan HSA Plan
UnitedHealthcare UnitedHealthcare
Network Select Plus Non-Network Select Plus Non-Network
Lifetime Maximum Unlimited Unlimited
Annual Deductible
Individual $750 $1,500 $2,000 $13,000
Family $1,500 $3,000 $2,600 $26,000
Coinsurance (Plan Pays) 80% 50% 80% 50%

Physician Office Visit
PCP $20 Copay 50% 80% 50%
Specialist $40 Copay 50% 80% 50%
Out-of-Pocket Maximum
Individual $5,500 $11,000 $6,500 $26,000
Family $11,000 $22,000 $13,000 $52,000
Hospitalization
Inpatient $250 Copay, 80% $250 Copay, 50% 80% 50%
Outpatient Surgery $250 Copay, 80% $250 Copay, 50% 80% 50%
Emergency Services $100 Copay 80%
Waived if Admitted
Urgent Care $50 Copay 50% 80% 50%
Preventive Care 100% Not Covered 100% (No Ded) Not Covered
Chiropractic $20 Copay 50% 80% 50%
Max 24 Visits/Year Max 24 Visits/Year

Acupuncture $20 Copay 50% 80% 50%
Prescription Drugs
Retail Pharmacy Plan Ded Applies Plan Ded Applies
– Supply Limit 30 Days 30 Days 30 Days 30 Days
– Tier 1 $15 Copay $15 Copay $20 Copay $20 Copay
– Tier 2 $35 Copay $35 Copay $50 Copay $50 Copay
– Tier 3 $60 Copay $60 Copay $100 Copay $100 Copay
– Tier 4 25% Max $250 25% Max $250 25% Max $250 25% Max $250
Mail Order Pharmacy
– Supply Limit 90 Days N/A 90 Days N/A
– Tier 1 $37.50 Copay Not Covered $50 Copay Not Covered
– Tier 2 $87.50 Copay Not Covered $125 Copay Not Covered
– Tier 3 $150 Copay Not Covered $250 Copay Not Covered
– Tier 4 25% Max $250 Not Covered 25% Max $500 Not Covered

FINDING A MEDICAL PROVIDER:
• UnitedHealthcare PPO and HSA: Login to www.myuhc.com or call (800) 357-0978. PPO and HSA members
should refer to the “UnitedHealthcare Select Plus” network

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