High-Deductible Health Plans

MEDICAL PLAN BENEFITS

Deductible

• Individual • Family Coinsurance (you pay)

Out-of-Pocket Maximum

(includes deductible) • Individual • Family

Physician Services

• Primary Physician Visit • Specialist Visit • Virtual Visit • Preventive Care

Inpatient Hospital Care Outpatient Surgery Emergency Room Care Urgent Care Center

Prescription Drugs – Retail Pharmacy

(up to a 31-day supply) • Preventive Medications • Tier 1 – Your Lowest Cost Option • Tier 2 – Your Mid-Range Cost Option • Tier 3 – Your Highest Cost Option

Prescription Drugs – Mail-Order

(up to a 90-day supply) • Preventive Medications • Tier 1 – Your Lowest Cost Option • Tier 2 – Your Mid-Range Cost Option • Tier 3 – Your Highest Cost Option

In-Network

HSA PLAN

Out-of-Network

$2,000 $4,000

$4,000 $8,000 20% after deductible 50% after deductible

$4,000 $8,000 $8,000 $16,000

20% after deductible 20% after deductible Up to $50 No charge

50% after deductible 50% after deductible Not covered Not covered 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible Once you meet the deductible, the copays below apply:

No charge $10 copay $50 copay $75 copay You pay the in-network copay plus all charges above UHC’s allowed amount. Once you meet the deductible, the copays below apply

No charge $25 copay $125 copay $187.50 copay Not covered

You must pay the full cost of your medical and non-preventive prescription drug expenses until you meet the annual deductible. The coinsurance and prescription drug copays shown apply only after the deductible has been paid.

Tips to Save Money

PREVENTIVE/WELLNESS EXAMS ARE COVERED AT 100%

• In-network preventive care is equal to one physical exam per year per enrolled member.

PRESCRIPTION DRUGS

• Ask your doctor if there is a generic version of the medication you’re taking. • Take advantage of the Generic

Prescription Savings Programs at major retailers. • Ask about free samples from your doctor and/or manufacturer rebates.

HIGH COST SCANS, X-RAYS & TESTS

• MRI, PET scans, CT scans, etc. are nearly 2/3 less costly at free-standing, in-network imaging centers than at hospitals. • Finding an in-network, free-standing imaging center can save you money.