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Home Delivery Incontinent Supply Co.
5
MEDICAL INSURANCE
Benefit Plan—BASE PLAN
In-Network
Out-of-Network
Deductible
(calendar year)
Single
$3,500
$6,000
Family
$7,000
$12,000
Coinsurance
(plan pays/you pay)
80% / 20%
60% / 40%
Out-of-Pocket Limit
(including the deductible + coinsurance + copayments)
Single
$6,000
$10,000
Family
$12,000
$20,000
Copayments
Primary Physician Visit
$25 co-pay
Deductible, then you pay 40%
Specialist Physician Visit
$50 co-pay
Deductible, then you pay 40%
Preventive Care*
Plan pays 100%
Deductible, then you pay 40%
Emergency Room Visit
$250 co-pay
$250 co-pay
Urgent Care Center Visit
$75 co-pay
Deductible, then you pay 40%
Prescription Drug Coverage
Retail Pharmacy
$10/35/60
$10/35/60**
Mail Order Pharmacy
$25/87.50/150
$25/87.50/150**
2015—2016 Employee Base Plan Medical Contributions
*Coverage for Preventive Care is mandated by Health Care Reform guidelines. Please refer to
www.healthcare.gov for a list of
preventive care services covered under this provision.
**If you purchase a Prescription Drug Product form a Non-Network Pharmacy, you are responsible for any difference between what
the Non-Network Pharmacy charges and the amount UHC would have paid for the same Prescription Drug Product dispensed by a
Network Pharmacy.
Employee Deduction (per
pay Period)
Employee
$39.91
Employee & Spouse
$320.92
Employee & Child(ren)
$247.76
Employee & Family
$540.39