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Donald Danforth Plan Science Center
7
MEDICAL INSURANCE
UnitedHealthcare Medical
Benefit Plan—QHDHP Plan
In Network
Out of Network
Deductible
(calendar year embedded deductible*)
Single
$2,600
$5,000
Family
$5,200
$10,000
Coinsurance
(plan pays/you pay)
100% / 0%
70% / 30%
Out of Pocket Limit
(including the deductible + coinsurance + copayments)
Single
$3,500
$10,000
Family
$7,000
$20,000
Copayments
Primary Physician Visit
Deductible, then you pay 0%
Deductible, then you pay 30%
Specialist Physician Visit
Deductible, then you pay 0%
Deductible, then you pay 30%
Preventive Care
Plan pays 100%
Deductible, then you pay 30%
Emergency Room Visit
Deductible, then you pay 0%
In Network Deductible, then 0%
Urgent Care Center Visit
Deductible, then you pay 0%
Deductible, then you pay 30%
Prescription Drug Coverage
Retail Pharmacy
Deductible then $10/35/60
Deductible & Coinsurance then
$10/35/60
Mail Order Pharmacy
Deductible then $25/87.50/150
Deductible & Coinsurance then
$25/87.50/150
2016 Employee QHDHP Plan Medical and Dental Contributions
*An
embedded
deductible means your plan contains two components, an individual deductible and a family
deductible. Having two components to the deductible allows for each member of your family the opportunity to have
the insurance policy cover their medical bills prior to the entire dollar amount of the family deductible being met. The
individual deductible is embedded in the family deductible.
Employee Deduction (for
Medical and Dental per pay
period)
Total
The
Center
Pays
Employee
Monthly
Cost
Employee
Per Pay
Period Cost
Employee Per Pay
Period Cost with
Spousal Surcharge
Employee
$431.85
$387.85
$44.00
$22.00
$22.00
Employee & Spouse
$903.52
$795.52
$108.00
$54.00
$79.00
Employee & Child(ren)
$840.44
$740.44
$100.00
$50.00
$50.00
Employee & Family
$1,279.30 $1,087.30
$192.00
$96.00
$121.00