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

CHOICE PLUS HSA PPO HDHP (MIDDLE PLAN)

CHOICE PLUS PPO HSA HDHP (LOW PLAN)

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

IN-NETWORK

OUT-OF-NETWORK

Individual:

$1,600 $3,200

Individual:

$3,000 $6,000

Annual Deductible (calendar year)

Individual:

$2,500 $5,000

Individual:

$5,000 $10,000 $11,600 $23,200

Family:

Family:

Family:

Family:

Out-of-Pocket Maximum (calendar year)

Individual:

$4,500 $9,000

Individual:

$9,000 $18,000

Individual:

$5,000 $10,000

Individual:

Family:

Family:

Family:

Family:

Coinsurance

UnitedHealthcare pays 80% Employee pays 20%

UnitedHealthcare pays 60% Employee pays 40%

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

100% 100% 100%

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

Outpatient Care Primary care physician office visits Specialist office visits

80% after deductible 80% after deductible

60% after deductible 60% after deductible

80% after deductible 80% after deductible

60% after deductible 60% after deductible

Inpatient Care

80% after deductible

$500 deductible plus 60% after plan deductible

80% after deductible

$500 deductible plus 60% after plan deductible

Outpatient Diagnostic Services Laboratory & Diagnostic X-rays

80% after deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible

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

80% after deductible Deductible; coinsurance waived Deductible; coinsurance waived

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

(Independent Clinical Lab) (Value Choice Specialist ) (Independent Diagnostic Testing Center)

80% after deductible 80% after deductible

Advanced Imaging (MRI. PET, CT) (office setting/outpatient facility)

Emergency Care Ambulance when medically necessary At hospital emergency room Urgent Care

80% after deductible 80% after deductible 80% after deductible

80% after In-Network deductible 80% after In-Network deductible 80% after deductible

80% after deductible 80% after deductible 80% after deductible

80% after In-Network deductible 80% after In-Network deductible 80% after In-Network deductible

Mental Health Inpatient Outpatient

80% after deductible 80% after deductible

60% after deductible 60% after deductible

80% after deductible 80% after deductible

60% after deductible 60% after deductible

Prescription Drugs Annual Deductible (calendar year)

Medical Deductible Applies Individual: $1,600 Family: $3,200

Medical Deductible Applies Individual: $3,000 Family: $6,000

Medical Deductible Applies Individual: $2,500 Family: $5,000

Medical Deductible Applies Individual: $5,000 Family: $10,000

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

$10/$35/$70 After deductible $25/$87.50/$175 After deductible

$10/$35/$70 After deductible $25/$87.50/$175 After deductible

$10/$35/$70 After deductible $25/$87.50/$175 After deductible

$10/$35/$70 After deductible $25/$87.50/$175 After deductible

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

Dependent Age Limit

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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