Heritage Tennessee Heritage Plus Split Copay Plans Out of Pocket Maximum Network Non- Network N/A N/A N/A N/A N/A $500 $1,000 $2,000 $2,000 $2,000 $3,000 $3,000 $3,000 $3,000 $3,000 $3,400 $4,000 $4,000 $4,000 $4,000 $4,000 $4,000 $4,000 $4,000 $4,000 $4,000 $500 $2,000 $5,000 $2,000 $2,000 $500 $2,000 $2,000 $2,000 $2,000 $3,000 $3,000 $3,000 $3,000 $3,000 $5,000 $4,000 $5,000 $5,000 $4,000 $4,000 $4,000 $4,000 $6,000 $3,500 $6,000 $1,000 $4,000 $10,000 $6,000 $4,000 $1,000 $4,000 $7,000 $4,000 $4,000 $6,000 $6,000 $6,000 $6,000 $6,000 $10,000 $8,000 $10,000 $10,000 $8,000 $8,000 $8,000 $8,000 $12,000 $7,000 $12,000 100% 100% 100% 90% 80% 90% 80% 80% 80% 80% 90% 90% 80% 80% 80% 80% 100% 100% 100% 90% 90% 80% 80% 80% 70% 70% 70% 60% 50% 60% 60% 70% 50% 60% 60% 60% 60% 70% 50% 50% 50% 60% 80% 75% 75% 70% 60% 60% 60% 60% 50% 50% $2,000 $2,000 $4,000 $4,000 $2,000 $1,500 $1,500 $3,500 $6,000 $6,000 $4,500 $6,000 $4,500 $6,000 $6,000 $4,000 $4,000 $5,000 $5,000 $6,000 $6,000 $4,000 $4,800 $6,000 $5,000 $6,250 $4,000 $3,000 $6,000 $4,000 $4,000 $8,000 $8,000 $15,000 $30,000 $12,000 $8,000 $24,000 $4,000 $4,000 $8,000 $3,000 $3,000 $6,000 $3,000 $5,000 $10,000 $7,000 $5,000 $10,000 $12,000 $12,000 $24,000 $12,000 $12,000 $24,000 $9,000 $9,000 $18,000 $12,000 $12,000 $24,000 $9,000 $9,000 $18,000 $12,000 $12,000 $24,000 $12,000 $12,000 $24,000 $8,000 $15,000 $30,000 $8,000 $8,000 $16,000 $10,000 $10,000 $20,000 $10,000 $10,000 $20,000 $12,000 $12,000 $24,000 $12,000 $12,000 $24,000 $8,000 $8,000 $16,000 $9,600 $12,000 $24,000 $12,000 $8,000 $16,000 $10,000 $7,000 $14,000 $12,500 $12,500 $25,000 Available Rx Code $500 Emb Sep $800 Emb Sep $800 Emb Sep 90% NonEmb Sep 80% Emb Sep 90% Emb Sep 80% Emb Sep 80% Emb Sep 80% Emb Sep 80% Emb Sep 90% Emb Sep 90% Emb Sep 80% Emb Sep 80% NonEmb Sep 80% Emb Sep 80% NonEmb Sep 100% Emb Sep 100% Emb Sep 100% Emb Sep 90% Emb Sep 90% Emb Sep 80% Emb Sep 80% Emb Sep 80% Emb Sep 70% Emb Sep 70% Emb Sep N N N N N N N N N N N N N N N N N N N N N N N N N N C60A C60A C60A C60A C60A C60A C90A C60A C60A C60A C60A C60A C60A C60A C60A C60A C60A D10A D50A C60A C60A C60A C60A D50A D50A C70A Member Copay/Plan Coinsurance NonSingle Family Single Family Network Single Family Single Family PCP SPEC UC Network N/A N/A N/A N/A N/A $250 $500 $1,000 $1,000 $1,000 $1,500 $1,500 $1,500 $1,500 $1,500 $1,700 $2,000 $2,000 $2,000 $2,000 $2,000 $2,000 $2,000 $2,000 $2,000 $2,000 HRA Eligible Split Copay Plans N6-C Platinum 25/100% N6-5 Platinum 20/100% N6-7 Platinum 15/100% N6-6 Platinum 20/90% N6-4 Platinum 25/80% N5-9 Platinum 15/250/90% OD-U Platinum 20/500/80% OD-W Gold 35/1000/80% N7-8 Gold 15/1000/80% OB-Y Gold 25/1000/80% OD-O Gold 25/1500/90% N9-A Gold 25/1500/90% OD-Q Gold 25/1500/80% OD-R Gold 15/1500/80% OD-V Gold 15/1500/80% OB-3 Gold 30/1700/80% N7-7 Gold 25/2000/100% OD-X Gold 20/2000/100% PA-V Silver 50/2000/100% OB-X Gold 25/2000/90% OB-1 Gold 15/2000/90% OB-W Gold 25/2000/80% OB-Z Gold 20/2000/80% OB-9 Silver 40/2000/80% OB-8 Silver 30/2000/70% OC-D Silver 50/2000/70% Plan Coinsurance Med/Rx Deductible Type Plan Metallic Plan Code Level Description Non-Network $25 $20 $15 $20 $25 $15 $20 $35 $15 $25 $25 $25 $25 $15 $15 $30 $25 $20 $50 $25 $15 $25 $20 $40 $30 $50 $50 $40 $30 $40 $50 $30 $40 $75 $30 $50 $50 $50 $50 $30 $30 $70 $50 $50 $100 $50 $60 $50 $50 $80 $95 $150 $75 $150 $150 $75 $75 $75 $75 $100 $100 $100 $100 $100 $100 $100 $100 $125 $100 $100 $125 $100 $150 $100 $100 80% $100 70% ER $100 $200 $250 $150 $150 $150 $125 $250 $200 $500 $200 $200 $200 $150 $200 $250 $200 $500 $500 $150 $300 $200 $200 80% $500 70% OP IP Surg Hosp $350 $650 $650 90% 80% 90% 80% 80% 80% 80% 90% 90% 80% 80% 80% 80% 100% 100% 100% 90% 90% 80% 80% 80% 70% 70% Deductible Typle Deductible Network 2-50 Eligible Employees For all plans listed: · All Plans have an Unlimited Lifetime Maximum · All Plans cover in network Preventive care at 100% Please Note: The information in this grid is provided for informational purposes only and is not intended for use as a contract. For a complete listing of coverage and exclusions please refer to the Certificate of Coverage or talk to your UnitedHealthcare representative for additional details that could impact the benefits. Different UnitedHealthcare plans may have varying approaches to whether pharmacy costs are included or excluded from the medical deductible. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare Insurance Company of the River Valley. Premium rates and/or product forms included herein are subject to approval by regulators. If rates or product forms offered herein are subsequently modified by regulators we will immediately advise you of the change in plan design and retroactively adjust premium in subsequent billings. ©2013 United HealthCare Services, Inc. UHCTN669159_003 2/17/14 2014 Broker Heritage Tennessee Heritage Plus Deductible Plans 300/80% 350/90% 450/95% 800/80% 1000/85% 1000/80% 1000/70% 1100/80% 1250/80% 2000/85% 2000/80% 2000/70% 2000/70% 3500/70% 4000/80% 4400/70% 4500/70% 4950/75% 5000/90% Out of Pocket Maximum Network Non- Network Member Copay/Plan Coinsurance NonSingle Family Single Family Network Single Family Single Family PCP SPEC UC Network $300 $350 $450 $800 $1,000 $1,000 $1,000 $1,100 $1,250 $2,000 $2,000 $2,000 $2,000 $3,500 $4,000 $4,400 $4,500 $4,950 $5,000 $750 $2,000 $6,000 $1,050 $2,000 $6,000 $1,350 $6,000 $18,000 $1,600 $3,000 $6,000 $2,000 $2,500 $5,000 $2,000 $3,000 $6,000 $2,000 $3,000 $6,000 $2,500 $3,000 $6,000 $2,500 $1,250 $2,500 $4,000 $4,000 $8,000 $4,000 $4,000 $8,000 $4,000 $6,000 $12,000 $4,000 $5,000 $10,000 $7,000 $7,000 $14,000 $8,000 $8,000 $16,000 $8,800 $8,000 $16,000 $9,000 $9,000 $18,000 $9,900 $9,900 $19,800 $10,000 $10,000 $20,000 80% 90% 95% 80% 85% 80% 70% 80% 80% 85% 80% 70% 70% 70% 80% 70% 70% 75% 90% 60% 60% 50% 60% 60% 60% 50% 60% 80% 50% 50% 50% 50% 50% 60% 50% 50% 50% 70% $1,300 $1,500 $1,650 $3,000 $4,000 $3,300 $2,800 $3,000 $3,000 $6,000 $6,250 $4,500 $5,800 $6,250 $6,250 $6,250 $6,250 $5,700 $6,000 $3,750 $6,000 $18,000 $4,500 $6,000 $18,000 $5,700 $18,000 $54,000 $6,000 $12,000 $24,000 $8,000 $8,000 $16,000 $8,000 $12,000 $24,000 $6,000 $12,000 $24,000 $6,000 $12,000 $24,000 $6,000 $3,000 $6,000 $12,000 $8,000 $16,000 $12,500 $12,500 $25,000 $9,000 $12,000 $24,000 $12,000 $15,000 $30,000 $12,500 $12,800 $25,600 $12,500 $12,800 $25,600 $12,500 $12,500 $25,000 $12,500 $18,000 $36,000 $11,400 $15,000 $30,000 $12,000 $20,000 $40,000 80% 90% 95% 80% 85% 80% 70% 80% 80% 85% 80% 70% 70% 70% 80% 70% 70% 75% 90% 80% 90% 95% 80% 85% 80% 70% 80% 80% 85% 80% 70% 70% 70% 80% 70% 70% 75% 90% 80% 90% 95% 80% 85% 80% 70% 80% 80% 85% 80% 70% 70% 70% 80% 70% 70% 75% 90% OP IP ER Surg Hosp 80% 90% 95% 80% 85% 80% 70% 80% 80% 85% 80% 70% 70% 70% 80% 70% 70% 75% 90% 80% 90% 95% 80% 85% 80% 70% 80% 80% 85% 80% 70% 70% 70% 80% 70% 70% 75% 90% 80% 90% 95% 80% 85% 80% 70% 80% 80% 85% 80% 70% 70% 70% 80% 70% 70% 75% 90% HRA Eligible Deductible N7-4 Platinum N7-5 Platinum N7-6 Platinum OB-2 Gold OB-5 Gold OB-7 Gold OB-6 Gold OB-4 Gold N5-8 Gold OC-H Silver OD-S Silver OC-C Silver OC-G Silver OC-K Bronze TI-1 Bronze OD-T Bronze OC-N Bronze OC-I Bronze OC-J Bronze Plan Coinsurance Med/Rx Deductible Type Plan Metallic Plan Code Level Description Non-Network Deductible Type Deductible Network 2-50 Eligible Employees Available Rx Code NonEmb NonEmb NonEmb Emb Emb NonEmb NonEmb Emb Emb Emb NonEmb Emb NonEmb Emb Emb NonEmb NonEmb Emb Emb Comb Comb Comb Comb Comb Comb Comb Comb Sep Comb Comb Sep Sep Comb Comb Comb Comb Comb Comb N N N N N N N N N N N N N N N N N N N C60A C60A C60A C60A C60A C60A C60A C60A C60A 202A C60A C70A C70A D30A 201A D30A D30A 200A 203A For all plans listed: · All Plans have an Unlimited Lifetime Maximum · All Plans cover in network Preventive care at 100% Please Note: The information in this grid is provided for informational purposes only and is not intended for use as a contract. For a complete listing of coverage and exclusions please refer to the Certificate of Coverage or talk to your UnitedHealthcare representative for additional details that could impact the benefits. Different UnitedHealthcare plans may have varying approaches to whether pharmacy costs are included or excluded from the medical deductible. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare Insurance Company of the River Valley. Premium rates and/or product forms included herein are subject to approval by regulators. If rates or product forms offered herein are subsequently modified by regulators we will immediately advise you of the change in plan design and retroactively adjust premium in subsequent billings. ©2013 United HealthCare Services, Inc. UHCTN669159_003 2/17/14 2014 Broker Heritage Heritage Plus Health Savings Account (HSA) and Health Reimbursement Account (HRA) Plans HRA Eligible Out of Pocket Maximum Med/Rx Deductible Type Plan Coinsurance Deductible Type Deductible Tennessee 2-50 Eligible Employees Available Rx Code 80% 95% 100% 70% 70% 80% $60 80% 70% 70% 75% 70% 80% 95% 100% 70% 70% 80% 100% 80% 70% 70% 75% 70% 80% 95% 100% 70% 70% 80% $100 80% 70% 70% 75% 70% 80% 95% 100% 70% 70% 80% 100% 80% 70% 70% 75% 70% 80% 95% 100% 70% 70% 80% $200 80% 70% 70% 75% 70% NonEmb NonEmb NonEmb NonEmb NonEmb NonEmb NonEmb NonEmb NonEmb Emb NonEmb NonEmb Comb Comb Comb Comb Comb Comb Comb Comb Comb Comb Comb Comb N N N N N N N N N N N N C60A C60A C60A C60A C60A C60A C80A C60A C60A D30A C60A D30A 50% 80% 70% 50% 80% 70% 50% 80% 70% 50% 80% 70% 50% 80% 70% Emb Emb Emb Sep Sep Sep Y Y Y C60A C60A C60A Member Copay/Plan Coinsurance Non- Network Employer Employer Plan Metallic Funding Funding Plan Code Level Amount Amount Description NonOP IP Single Family Single Family Network Single Family Single Family PCP SPEC UC ER Min Max Network Surg Hosp Network Health Savings Account (HSA) Plans 49-H Gold $750 $1,100 2000/80% OC-Q Gold $0 $0 1350/95% OC-P Gold $0 $0 1500/100% 49-F Silver $100 $350 2000/70% OD-G Silver $0 $0 1500/70% OD-D Silver $0 $0 1800/80% 25/2000/100% OC-R Silver $0 $0 OD-C Silver $0 $0 2000/80% OD-H Silver $0 $0 2000/70% OD-M Bronze $0 $0 3500/70% OD-K Bronze $0 $0 4900/75% OD-N Bronze $0 $0 5000/70% Health Reimbursement Account (HRA) Plans 49-D Platinum $2,000 $2,000 2000/50% 49-C Gold $600 $950 2000/80% 49-B Silver $0 $150 2000/70% $2,000 $1,350 $1,500 $2,000 $1,500 $1,800 $2,000 $2,000 $2,000 $3,500 $4,900 $5,000 $4,000 $2,800 $4,500 $4,000 $3,000 $3,600 $3,500 $3,000 $5,000 $7,000 $7,350 $10,000 $2,000 $4,000 $2,000 $4,000 $2,000 $4,000 Non-Network $6,000 $2,600 $5,000 $5,000 $3,000 $4,000 $4,000 $3,000 $7,500 $7,000 $6,000 $10,000 $12,000 $5,200 $15,000 $10,000 $6,000 $8,000 $6,000 $4,500 $18,750 $14,000 $18,000 $20,000 $6,000 $12,000 $6,000 $12,000 $5,000 $10,000 Network 80% 95% 100% 70% 70% 80% 100% 80% 70% 70% 75% 70% 50% 75% 70% 50% 50% 50% 60% 60% 50% 50% 55% 50% $6,250 $5,000 $4,000 $6,250 $6,000 $5,000 $3,000 $4,200 $4,500 $6,250 $5,500 $6,250 $12,500 $12,000 $12,000 $12,500 $12,000 $10,000 $4,500 $6,300 $10,000 $12,500 $8,250 $12,500 $19,200 $7,500 $10,000 $10,000 $12,000 $8,000 $6,000 $6,400 $12,000 $12,800 $7,500 $12,000 $38,400 $15,000 $30,000 $20,000 $24,000 $16,000 $9,000 $9,600 $37,500 $25,600 $22,500 $24,000 80% 95% 100% 70% 70% 80% $25 80% 70% 70% 75% 70% 50% 80% 70% 50% 50% 50% $4,000 $8,000 $19,200 $38,400 50% $6,250 $12,500 $19,200 $38,400 80% $6,250 $12,500 $10,000 $20,000 70% In 2014, maximum HSA contribution is $3,300 single/$6,550 family. These amounts are subject to change by the IRS and do not include catch-up contributions for subscribers age 55 and over. The UnitedHealthcare Health Savings Account (HSA) high-deductible health plan (HDHP) is designed to comply with IRS requirements so eligible enrollees may open a Health Savings Account with a bank of their choice or through Optum BankSM, Member FDIC. “UnitedHealthcare HSA” refers generally to the UnitedHealthcare HSA product, which includes a HDHP, although at times “UnitedHealthcare HSA” may refer only and specifically to the UnitedHealthcare Health Savings Account, provided in conjunction with Optum Bank and not to the associated HDHP. For all plans listed: · All Plans have an Unlimited Lifetime Maximum · All Plans cover in network Preventive care at 100% Please Note: The information in this grid is provided for informational purposes only and is not intended for use as a contract. For a complete listing of coverage and exclusions please refer to the Certificate of Coverage or talk to your UnitedHealthcare representative for additional details that could impact the benefits. Different UnitedHealthcare plans may have varying approaches to whether pharmacy costs are included or excluded from the medical deductible. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare Insurance Company of the River Valley. Premium rates and/or product forms included herein are subject to approval by regulators. If rates or product forms offered herein are subsequently modified by regulators we will immediately advise you of the change in plan design and retroactively adjust premium in subsequent billings. ©2013 United HealthCare Services, Inc. UHCTN669159_003 2/17/14 2014 Broker Heritage Tennessee Heritage Plus Primary Advantage Plans HRA Eligible Out of Pocket Maximum Med/Rx Deductible Type Plan Coinsurance 2 Deductible Type Deductible 1 Network Non-Network 2-50 Eligible Employees Available Rx Code OK-P Gold 25/500/100% $500 $1,000 $1,000 $2,000 100% 70% $1,500 $3,000 $3,000 $6,000 $25 $50 $75 $250 $300 $500 Emb Sep N C60A TM-T Gold 20/750/100% $750 $1,500 $1,500 $3,000 100% 70% $2,000 $4,000 $4,000 $8,000 $20 $40 $75 $200 $100 $250 Emb Sep N C60A OK-O Gold 15/1000/100% $1,000 $2,000 $2,000 $4,000 100% 70% $3,000 $6,000 $6,000 $12,000 $15 $30 $75 $250 $100 $300 Emb Sep N C60A OK-R Silver 40/750/100% $750 $1,500 $1,500 $3,000 100% 70% $2,000 $4,000 $4,000 $8,000 $40 $80 $125 $500 $250 $1,000 Emb Sep N 204A TM-U Silver 35/1000/100% $1,000 $2,000 $2,000 $4,000 100% 70% $3,000 $6,000 $6,000 $12,000 $35 $70 $100 $250 $500 Sep N C70A Silver $50 Plan Metallic Plan Code Level Description Network Non- Network Member Copay/Plan Coinsurance Single Family Single Family In Out Single Family Single Family PCP SPEC UC ER OP IP Surg Hosp Primary Advantage Plans OK-Q $750 Emb 20/2000/100% $2,000 $4,000 $4,000 $8,000 100% 70% $5,000 $10,000 $10,000 $20,000 $20 $100 $250 $300 $500 Emb Sep N 204A TM-V Bronze 50/2500/100% $2,500 $5,000 $5,000 $10,000 100% 70% $6,000 $12,000 $10,000 $20,000 $50 $100 $100 $350 $500 $750 Emb Sep N C70A OK-S Bronze 50/3000/100% $3,000 $6,000 $5,000 $10,000 100% 70% $6,000 $12,000 $10,000 $20,000 $50 $100 $125 $500 $350 $1,000 Emb Sep N C70A TM-W Bronze 50/3000/100% $3,000 $6,000 $5,000 $10,000 100% 70% $6,000 $12,000 $10,000 $20,000 $50 $100 $150 $250 $350 Sep N C70A $750 Emb 1 Pre-Deductible Services (Deductible does not apply): Preventive Care Visits, PCP Office Visits, PCP Office Surgery, PCP Allergy Testing. Services received from a specialist, including an OB/GYN for prenatal visits, will be subject first to the deductible. Once the deductible is satisfied, then the member copay applies. 2 The following services will be subject to In-Network Coinsurance less than 100%: Ambulance, Skilled Nursing Facility, Allergy & Other Injections, Out-patient Chemotherapy, Hospice. For all plans listed: · All Plans have an Unlimited Lifetime Maximum · All Plans cover in network Preventive care at 100% Please Note: The information in this grid is provided for informational purposes only and is not intended for use as a contract. For a complete listing of coverage and exclusions please refer to the Certificate of Coverage or talk to your UnitedHealthcare representative for additional details that could impact the benefits. Different UnitedHealthcare plans may have varying approaches to whether pharmacy costs are included or excluded from the medical deductible. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare Insurance Company of the River Valley. Premium rates and/or product forms included herein are subject to approval by regulators. If rates or product forms offered herein are subsequently modified by regulators we will immediately advise you of the change in plan design and retroactively adjust premium in subsequent billings. ©2013 United HealthCare Services, Inc. UHCTN669159_003 2/17/14 2014 Broker Heritage Tennessee Heritage Plus Pharmacy Plans 2-50 Eligible Employees Member Copay/Coinsurance Deductible Tier 2 Tier 3 Tier 4 Single Family Mail Service Ratio (x Retail) $15 $35 $50 $45 $50 $65 $50 $60 $75 $65 $75 $100 $100 $100 $125 $125 $125 $200 $$$$$$- $$$$$$- 2.5 2.5 2.5 2.5 2.5 3.0 $35 $40 10% 15% 20% 25% 30% $60 $60 10% 15% 20% 25% 30% $100 $125 10% 15% 20% 25% 30% Rx Plan Code Tier 1 C90A $7 C60A $10 204A $10 D10A $15 C70A $15 D50A $20 Combined Med/Rx Deductible C60A $10 C80A $20 203A 10% 202A 15% 201A 20% 200A 25% D30A 30% Same as Same as Same as Same as Same as Same as Same as Medical Medical Medical Medical Medical Medical Medical Same as Same as Same as Same as Same as Same as Same as Medical Medical Medical Medical Medical Medical Medical 2.5 2.5 2.5 2.5 2.5 2.5 2.5 Coinsurance amounts reflect Member cost share. * Deductible does not apply to Tier 1 prescription drugs. Please Note: The information in this grid is provided for informational purposes only and is not intended for use as a contract. For a complete listing of coverage and exclusions please refer to the Certificate of Coverage or talk to your UnitedHealthcare representative for additional details that could impact the benefits. Different UnitedHealthcare plans may have varying approaches to whether pharmacy costs are included or excluded from the medical deductible. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or through UnitedHealthcare Insurance Company of the River Valley. Premium rates and/or product forms included herein are subject to approval by regulators. If rates or product forms offered herein are subsequently modified by regulators we will immediately advise you of the change in plan design and retroactively adjust premium in subsequent billings. ©2013 United HealthCare Services, Inc. UHCTN669159_003 2/17/14 2014 Broker
© Copyright 2024 ExpyDoc
