Medical Benefits Summary 2018

UNITEDHEALTHCARE
ENHANCED STANDARD HSA
COVERAGE LEVEL EMPLOYEE CONTRIBUTIONS PER SEMI MONTHLY PAY PERIOD

Employee Only $96.50 $60.50 $32.00

Employee + Spouse/Domestic
$224.00 $151.50 $95.00
Partner

Employee + Child(ren) $200.50 $122.00 $76.00

Family $373.00 $253.00 $158.50

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

ENHANCED STANDARD HSA

MEDICAL Network Out of Network Network Out of Network Network Out of Network
Deductible & Deductible & Deductible & Deductible &
Specialist Visit $50 copay $50 copay
Coinsurance Coinsurance Coinsurance Coinsurance
Deductible & Deductible & Deductible & Deductible &
Urgent Care $50 copay $50 copay
Coinsurance Coinsurance Coinsurance Coinsurance
Chiropractic Care (30 visits Deductible & Deductible & Deductible & Deductible &
$50 copay $50 copay
per calendar year) Coinsurance Coinsurance Coinsurance Coinsurance
Hospital (inpatient & Deductible & Deductible & Deductible & Deductible & Deductible & Deductible &
outpatient) Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance
Outpatient Services (lab, xray, Deductible & Deductible & Deductible & Deductible & Deductible & Deductible &
surgery, etc.) Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance
Deductible &
Emergency Room $250 copay $250 copay
Coinsurance
$30 copay
$30 copay (first visit Deductible & Deductible & Deductible & Deductible &
Maternity services
only) Coinsurance Coinsurance Coinsurance Coinsurance
(first visit only)
Infertility Services ($25,000
lifetime maximum for medical, Deductible & Deductible & Deductible &
Not covered Not covered Not covered
$10,000 lifetime maximum for Coinsurance Coinsurance Coinsurance
Rx)
PRESCRIPTION DRUGS*
Retail Mail Order Retail Mail Order Retail Mail Order
(30 day supply) (90 day supply) (30 day supply) (90 day supply) (30 day supply) (90 day supply)
Deductible & Deductible &
Tier 1 $10 copay $20 copay $10 copay $20 copay
Coinsurance Coinsurance
Deductible & Deductible &
Tier 2 $50 copay $100 copay $50 copay $100 copay
Coinsurance Coinsurance
Deductible & Deductible &
Tier 3 $75 copay $150 copay $75 copay $150 copay
Coinsurance Coinsurance

*Note, the majority of pharmacies participate in the OptumRx network. In the event
you choose an out of network pharmacy, you are responsible for the difference
between the predominant reimbursement rate and a network pharmacys usual and
customary charge
DISCLAIMER: This medical plan summary briefly describes the medical
benefits offered under the Dentsu Aegis Network BenefitsPLUS Program. If
there is a conflict between this information and medical plans legal documents,
the legal plan documents will govern. Dentsu Aegis Network reserves the right
to change, modify, or terminate these benefits without notice.