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2016-2017 Benefits Guide
4
Traditional PPO Plan
UHC Buy Up Plan Summary
(E9J, 2V)
Benefit/Service
In-Network
Out-of-Network
Deductible
(Individual/family)
$1,500 / $3,000
$4,500 / $9,000
Coinsurance
80%
50%
Out-of-Pocket Max.
(Individual/family)
$6,250 / $12,500
$12,500 / $25,000
Office Visit
$35/70 Co-Pay
50% after Deductible
Well care Benefits
100%
50% after Deductible
Lab & X-ray
80% after Deductible
50% after Deductible
Major Diagnostics
$400 Co-Pay
50% after Deductible
Inpatient Hospital
80% after Deductible
50% after Deductible
Outpatient Surgery
80% after Deductible
50% after Deductible
Emergency Room
$300 Co-Pay, then 20%
Urgent Care
$100 Co-Pay After Deductible
70% After Deductible
Prescription:
Retail
Mail Order
$10 / $35 / $60
$25 / $87.50 / $150
Type of
Coverage
Employee
Bi-Weekly
Cost
Employee
$45.86
Employee & Spouse
$198.66
Employee & Child(ren)
$184.48
Employee & Family
$288.54
This may be the plan for you if:
You prefer copays for services like maintenance
medications or frequent office visits
You have children who go to the doctor frequently
You cannot afford the high deductible in HSA
You would rather pay more in bi-weekly premium
contributions and less on medical expenses when they occur
You are not interested in establishing a Health Savings
Account
You are 65, or on Medicare