JC - 2024 Employee Benefits Guide - (FINAL 11.28.2023) SPR

CHOICE PLUS PPO PLAN (HIGH PLAN)

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Annual Deductible (calendar year)

Individual:

$1,500 $3,000

Individual:

$3,000 $9,000

Family:

Family:

Out-of-Pocket Maximum (calendar year)

Individual:

$5,000 $10,000

Individual:

$8,000 $16,000

Family:

Family:

Coinsurance

UnitedHealthcare pays 80% Employee pays 20%

UnitedHealthcare pays 60% Employee pays 40%

Preventive Care Adult Preventive Care Adult Annual Physical Exam Well-Child Care

100% 100% 100%

60% after deductible 60% after deductible 60% after deductible

Inpatient Care

80% after deductible

60% after deductible

Outpatient Care Primary care physician office visits Specialist office visits Outpatient Diagnostic Services Surgery Laboratory & Diagnostic X-rays (Designated Network) (Advanced Imaging (MRI. PET, CT) (Designated Network) Emergency Care Ambulance when medically necessary At hospital emergency room Urgent Care

100% after $25 Copay 100% after $50 Copay

60% after deductible 60% after deductible

20% after deductible No Charge 100% $450 copay per visit

60% after deductible 60% after deductible 60% after deductible 60% after deductible 60% after deductible

80% after deductible 80% after deductible 100% after $55 Copay

80% after in-network deductible 80% after in-network deductible 60% after deductible

Mental Health Inpatient Outpatient

20% after deductible 100% after $25 Copay

60% after deductible 60% after deductible

Prescription Drugs Annual Deductible (calendar year)

None

None

Retail Pharmacy (30 day supply) Tier 1/Tier 2/Tier 3 Mail Order (90 day supply) Tier 1/Tier 2/Tier 3

$10/$50/$85

$10/$50/$85

$25/$125/$212.50

$25/$125/$212.50

Dependent Age Limit

To age 30 (coverage terminates at the end of the calendar year in which the dependent turns 30)

For additional information, please refer to your detailed plan summary. In the event of a discrepancy, the carrier Plan Document shall prevail.

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