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UNITEDHEALTHCARE
ENHANCED STANDARD HSA
COVERAGE LEVEL EMPLOYEE CONTRIBUTIONS PER SEMI MONTHLY PAY PERIOD
Employee + Spouse/Domestic
$224.00 $151.50 $95.00
Partner
MEDICAL Network Out of Network Network Out of Network Network Out of Network
Annual Deductible
- Single $500 $1,000 $1,000 $2,000 $2,000 $4,000
- Family $1,000 $2,000 $2,000 $4,000 $4,000 $8,000
Out of Pocket Maximum
- Single $4,000 $8,000 $4,000 $8,000 $4,000 $12,000
- Family $8,000 $16,000 $8,000 $16,000 $6,850 $24,000
$500 single
Employer HSA Contribution N/A N/A
$1,000 family
Coinsurance 90% 80% 80% 60% 80% 60%
Deductible & Deductible & Deductible &
Preventative Care 100% 100% 100%
Coinsurance Coinsurance Coinsurance
Deductible &
Virtual Visit $15 copay Not covered $15 copay Not covered Not Covered
Coinsurance
Deductible & Deductible & Deductible & Deductible &
Primacy Care Visit $30 copay $30 copay
Coinsurance Coinsurance Coinsurance Coinsurance
Benefits
2018 Medical Benefits Summary 2
*Note, the majority of pharmacies participate in the OptumRx network. In the event DISCLAIMER: This medical plan summary briefly describes the medical
you choose an out of network pharmacy, you are responsible for the difference benefits offered under the Dentsu Aegis Network BenefitsPLUS Program. If
between the predominant reimbursement rate and a network pharmacys usual and there is a conflict between this information and medical plans legal documents,
customary charge the legal plan documents will govern. Dentsu Aegis Network reserves the right
to change, modify, or terminate these benefits without notice.