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8
Your Medical Insurance Plan Options and Costs
Below are the per paycheck costs associated with each of the two medical plan options being offered for 2016/ 2017 plan year.
Please note that your premiums will be withheld from your paycheck on a pre-tax basis for medical, dental and vision insurance. This
can save you considerable money as the savings are based upon your individual tax bracket. Your election can only be changed mid
plan year if you experience a qualifying life status change. You must notify Human Resources within 30 days of the event.
NOTE: If you purchase a Prescription Drug Product from a Non-Network Pharmacy, you are responsible for any difference between
what the Non-Network Pharmacy charges and the amount UnitedHealthCare would have paid for the same Prescription Drug Product
dispensed by a Network Pharmacy.
Both plans are included in UnitedHealthcare’s 2016
Certificate of Coverage (COC). This is a brief summary
only. For exact terms and conditions, please refer to
your summary plan description.
Per Paycheck Employee Cost
Type of Coverage
Traditional PPO
Plan
QHDHP with
HSA Option
Employee
$109.58
$40.03
Employee & Spouse
$339.11
$200.00
Employee & Child(ren)
$281.73
$160.01
Employee & Family
$511.25
$319.99
UnitedHealthcare - Plan Designs
Features
Traditional PPO Plan
Qualified High Deductible Health Plan
(QHDHP) with HSA Option
In-Network
Out-of-Network
In-Network
Out-of-Network
Deductible
(Individual / Family)
$1,000 / $2,000
$3,000 / $6,000
$2,600 / $5,200
$7,500 / $15,000
Coinsurance
80%
50%
100%
70%
Out-of-Pocket Maximum
(Individual / Family)
Includes Deductible, Coinsurance & Co-Pay
$4,000 / $8,000
$8,000 / $16,000
$6,250 / $12,500
$12,500/ $25,000
Office Visit
(Primary Care physician / Specialist)
$30 / $60 Co-Pay 50% after Deductible
$35 / $70 Co-Pay
After Deductible
70% after deductible
Preventive Care
100%
50% after Deductible
100%
70% after deductible
Diagnostics:
Lab and X-Ray
Major Diagnostics (MRI, CT, PET…)
100%
80% after Deductible
50% after Deductible
50% after Deductible
100% after Deductible
100% after Deductible
70% after deductible
70% after deductible
Urgent Care
$100 Co-Pay
50% after Deductible
$100 Co-Pay
After Deductible
70% after deductible
Emergency Room
$300 Co-Pay
$300 Co-Pay after In-Network Deductible
Outpatient Surgery
80% after Deductible 50% after Deductible 100% after Deductible 70% after deductible
Inpatient Hospital Services
80% after Deductible 50% after Deductible 100% after Deductible 70% after deductible
Prescription Drug
Retail (at Participating Pharmacies)
Mail Order (90-Day Supply)
$10/$35/$60
$25/$87.50/$150
Deductible, then $10/$35/$60 Co-Pay
Deductible, then $25/$87.50/$150 Co-Pay