MEDICAL INSURANCE
Electronic Data, Inc. offers two medical plans through UnitedHealthcare. To find participating providers go to www.myuhc.com and click on “Find Physician”, choose the appropriate plan type. In Step 2: Enter zip code and type of provider. Complete the remaining information and click Search.
The chart below provides a brief overview of the medical plans. This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
Option 1 Choice Plus (Edge) FQ3
Option 2 Choice Plus FXT
IN-NETWORK: Plan Year or Calendar Year Basis
Policy Year
Policy Year
Deductible (Individual / Family)
$2,000 / $6,000
$1,500 / $4,500
Coinsurance
100%
100%
Maximum Out-of-Pocket (Individual/Family)
$4,000 / $8,000
$1,500 / $4,500
Maximum Out-of-Pocket Includes
Deductible, Coinsurance & Copays
Deductible, Coinsurance & Copays
Lifetime Maximum
Unlimited
Unlimited
PREVENTIVE CARE:
Wellness Immunizations Mammography/Colonoscopy COPAYMENTS: Referral Required Office Visits Consultations for Illness/Injury
Covered 100%
Covered 100%
No
No
$30 Copay
$25 Copay
$30 Copay (Designated) $60 Copay (Non-Designated)
Specialist Visits
$50 Copay
$500 Per Occurrence Deductible, then Deductible $250 Per Occurrence Deductible, then Deductible
Inpatient Hospital
Deductible
Outpatient Surgery
Deductible
Emergency Room Urgent Care
$250 Copay $100 Copay
$200 Copay $75 Copay
OUTPATIENT DIAGNOSTIC SERVICES: Independent/Freestanding Lab Complex Diagnostic (MRI, CT, PET, Etc.) – Freestanding Facility
Covered 100%
Covered 100%
$200 Copay
$200 Copay
PRESCRIPTIONS:
Tier 1: $15 Copay Tier 2: $45 Copay Tier 3: $85 Copay
Tier 1: $10 Copay Tier 2: $35 Copay Tier 3: $60 Copay
Retail (30 day supply)
OUT-OF-NETWORK 2 Deductible (Individual / Family)
$4,000 / $12,000
$3,000 / $9,000
Maximum Out-of-Pocket (Individual/Family)
$8,000 / $16,000
$6,000 / $12,000
Coinsurance
50 / 50%
80 / 20%
3
Made with FlippingBook Annual report