2012 Benefits- National Under 65 BENEFITS Retiree Monthly Rates - Harris In-network annual deductible Annual out-of-pocket limit Lifetime maximum Out of network option Fitness Center HOSPITAL / Inpatient Care Hospital care (semi-private room), surgery, x-rays and lab Skilled Nursing Facility URGENT CARE EMERGENCY CARE Emergency Room Emergency transportation OUTPATIENT CARE Office visit Immunizations and injections UNITED HEALTHCARE PPO BLUE CROSS/BLUE SHIELD PPO AETNA HMO Open Access Group # 195643 Group #13570-00 Group # 813972 Single: $484.97 Two-person: $969.94 Family: $1,454.90 None Single, $1,500; family $3,000; prescription copayments per person, $2,500 Single: $469.52 Two-person: $939.06 Family: $1,408.59 None Single, $1,250; family $2,500; prescription copayments per person, $2,500 None Annual deductible: single, $500; family $1,500; Then 70% to Out of pocket limit ($3,000/$6,000) None None Annual deductible: single, $500; family $1,500; Then 70% to Out of Pocket limit ($2,500/$5,000) None $250 copay per admission, then 85% coverage 85% coverage, up to 120 days per confinement $25 copay, then 85% $250 copay, then 90% coverage $250 copay, then 100% coverage 90% coverage $250 copay, then 100% coverage $20 copay, then 90% $25 copay, then 100% $100 copay, then 85% coverage; copay waived if admitted 85% coverage $100 copay, then 90% coverage; copay waived if admitted 90% coverage $100 copay, then 100% coverage; copay waived if admitted 100% coverage $25 copay, PCP; $35 copay, specialist $20 copay, PCP; $30 copay, specialist $25 copay, PCP; $35 copay, specialist $7 copay 90% coverage ; Adult and pediatric immunizations through Preventive Care 100% coverage Highmark Preventive Schedule; Routine Physical, $20 copay, PCP; $30 copay, specialist $25 copay, PCP; $35 copay, specialist. No serum copay Preventive care (care covered $25 copay, PCP; $35 copay, specialist under the Affordable Care Act is reimbursed at 100% with no copay) Maternity care $25 copay for first visit, then 15% 90% coverage coinsurance of global obstetrician's fee Pediatric care $25 copay, includes well baby and child care $20 copay, includes well baby and child care, 100% immunizations Gynecological care $25 copay $20 copay 90% coverage for all diagnostic lab and xX-ray, lab and diagnostic testing Included in copay if performed in a physician's office, otherwise 85% coverage ray Single: $478.28 Two-person: $956.58 Family: $1,434.86 None Single, $1,500; family $3,000; including copayments; prescription copayments per person, $2,500 None None GlobalFit Discount Program $25 copay, PCP; $35 copay, specialist Inpatient maternity care 100% after $250 copay $25 copay $25 copay $35 copay, for lab and x-rays performed in outpatient facility. Office copay applies to diagnostic testing performed in a physician's office. 2012 Benefits- National Under 65 UNITED HEALTHCARE PPO BLUE CROSS/BLUE SHIELD PPO AETNA HMO Open Access OTHER BENEFITS Mental health Outpatient $35 copay, visit Inpatient $250 copay per admission, then 85% coverage $30 copay per visit $250 copay per admission, then 90% coverage $35 copay per visit $250 copay per admission, then 100% coverage $30 copay, visit $250 copay per admission, then 90% coverage 90% coverage $35 copay per visit $250 copay per admission, then 100% coverage $35 copay per visit $30 copay, visit; limited to 30 visits per calendar year $35 copay, 60 visits per calendar year 90% coverage 90% coverage 30-day Supply: Generic - $7 copay Formulary - 20% (Min-$25; Max $75) Non-Formulary - (50% Min - $50; Max $100) Mail Order 90-day Supply: $17.50, 20% $62.50, $187.50 and 50%, $125, $250 copays. Administered through ExpressScripts (http://www.expresscripts.com) 100% coverage 100% coverage 30-day Supply: Generic - $7 copay Formulary - 20% (Min-$25; Max $75) Non-Formulary - (50% Min - $50; Max $100) Mail Order 90-day Supply: $17.50, 20% - $62.50, $187.50 and 50%, $125, $250 copays. Administered through ExpressScripts (http://www.expresscripts.com) Routine Exam None None Materials None None $35 copay, one routine exam per 24 months; through Vision One Discount Program Discounts available through Vision One Discount Program Substance abuse Outpatient $35 copay, visit Inpatient $250 copay per admission, then 85% coverage Cancer care (radiation therapy $35 copay, visit and chemotherapy) Outpatient Short-term speech, $35 copay, visit; limited to 20 visits per physical, occupational and calendar year respiratory therapy Medical Supplies Prosthetics 85% coverage Durable Medical 85% coverage Prescriptions 30-day Supply: Generic - $7 copay Formulary - 20% (Min-$25; Max $75) Non-Formulary - (50% Min - $50; Max $100) Mail Order 90-day Supply: $17.50, 20% $62.50, $187.50 and 50%, $125, $250 copays. Administered through ExpressScripts (http://www.expresscripts.com) Vision Hearing Chiropractic Routine Exam None Materials None $35 copay, visit; $1,500 limit Website/Provider Directory Product Name https://www.myuhc.com Choice Plus PPO None None $30 copay, visit; limited to 20 visits per calendar year www.mybenefitshome.com None None $35 copay, limited to 20 visits per year http://www.aetna.com/docfind/ Aetna Select (SM) Open Access *The above contains a brief overview of the various benefit programs and does not describe any plan, its provisions or limitations in any detail. Please refer to the benefit plan booklet for more information.