2013 Benefits UNITED HEALTHCARE POS Health First HMO Retirees Under 65 Brevard County, FL Group # 195643 Group # 113348 Monthly Rates BENEFITS 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 Single: $601.01 Two Person: $1,202.03 Family: $1,803.04 Single: Two Person: Family: $563.24 $1,126.49 $1,689.73 Single, $1,500; family $3,000; Pharmacy, $2,500/person None Annual deductible: single, $500; family $1,500; Then 70% coverage to out-ofpocket limit ($3,000/$6,000) None Single, $1,500; family $3,000; Pharmacy, $2,500/person None None $250 copay per admission, then 85% coverage; Wuesthoff Hospital - 95% coverage with no copay. 85% coverage, up to 120 days per confinement $250 copay per admission, then 100% coverage $25 copay, then 85% coverage $25 copay, then 100% coverage $100 copay, then 85% coverage; copay waived if admitted 85% coverage $100 copay, then 100% coverage; copay waived if admitted 100% coverage Membership to Pro-Health or Parrish Fitness centers for all covered family members age 13 or older. 100% coverage, up to 120 days per calendar year URGENT CARE EMERGENCY CARE Emergency Room Emergency transportation 2013 Benefits UNITED HEALTHCARE POS Health First HMO Retirees Under 65 OUTPATIENT CARE Office visit Injections $25 copay, PCP; $35 copay, specialist, then 100% coverage. Harris Family Medical Center - $15 copay, PCP $7 copay, then 100% coverage $25 copay, PCP; $35 copay, specialist, then 100% coverage; Harris Family Medical Center $15 copay, PCP $7 copay, then 100% coverage for allergy shots Preventive care (Care covered under $25 copay, PCP; $35 copay, specialist, $25 copay, PCP; $35 copay, specialist, then the Affordable Care Act is reimbursed then 100% coverage; 100% coverage; at 100% with no copay) Harris Family Medical Center, $15 copay, Harris Family Medical Center - $15 copay, PCP PCP Gynecological care (Care covered $25 copay, then 100% coverage $25 copay, then 100% coverage under the Affordable Care Act is reimbursed at 100% with no copay) X-ray, lab and diagnostic testing Included in copay if performed in a 100% coverage. All outpatient, nonphysician's office, otherwise 85% emergency diagnostic imaging must be coverage. All outpatient, non-emergency performed at UCI with applicable copayments. diagnostic imaging must be performed at UCI with applicable copayments. OTHER BENEFITS Mental health/Substance use disorder Outpatient $35 copay, then 100% coverage Inpatient $250 copay per admission, then 85% coverage $35 copay, then 100% coverage $250 per admission, then 100% coverage 2013 Benefits UNITED HEALTHCARE POS Health First HMO Retirees Under 65 Cancer care (radiation therapy and chemotherapy) $35 copay, then 100% coverage; 100% coverage if provided in office without other services Outpatient short-term speech, $35 copay, then 100% coverage; limited physical, occupational and respiratory to 20 visits per calendar year therapy Medical supplies Prosthetics 85% coverage Durable medical 85% coverage 100% coverage $35 copay, then 100% coverage 100% coverage; $2,500 annual maximum (combined with Durable Medical) 100% coverage, $2,500 annual maximum (combined with Prosthetics) Prescriptions Retail - 30-day Supply: Administered through ExpressScripts Generic - $7 copay (https://www.express-scripts.com) Formulary - 20% (Min $25; Max $75) Non-Formulary - 50% (Min $50; Max $100) HFMC pharmacy - 30-day Supply: Generic - $5 copay Formulary - 20% (Min $18.75; Max $56.25) Non-Formulary - 50% (Min $37.50; Max $75) Mail Order - 90-day Supply: Generic - $17.50 Formulary - 20% ($62.50; $187.50) Non-Formulary - 50% ($125; $250) Vision Routine exam and Materials Not covered Hearing (Care covered under the Affordable Care Act is reimbursed at 100% with no copay) Routine exam and Materials Not covered Not covered Not covered 2013 Benefits UNITED HEALTHCARE POS Health First HMO Retirees Under 65 Chiropractic Website/Provider directory $35 copay, then 100% coverage; $1,500 $35 copay, then 100% coverage limit https://www.myuhc.com http://www.healthfirst.org/health_plans/aso/index.cfm Product name Select Plus POS Harris EPO 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.