UNITEDHEALTHCARE HEALTH SAVINGS ACCOUNT PLAN 2015 BENEFITS SUMMARY

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1 UNITEDHEALTHCARE HEALTH SAVINGS ACCOUNT PLAN 2015 BENEFITS SUMMARY Member Service: To obtain list of providers New Participants: Web Site: Enrolled Participants: Web Site: Group # If you have a question about a specific coverage feature, treatments, or administrative process, contact the health plan directly PLAN FEATURES IN-NETWORK BENEFITS OUT-OF-NETWORK BENEFITS Enrollment Form Not Required Selection of Primary Care Physician Referrals Not Required Not Required Lifetime Maximum None Employer Contribution via Health Savings Account (HSA) fund contribution (You must open a bank account with Optum bank before funds can be deposited into your account) Employee Maximum Contribution to HSA Catch-Up Contributions (Applies to Employees 55 and Older) Deductible: Individual/Family $1,500/$3,000 (family deductible must be met before plan benefits start to pay out) Out-of-Pocket Maximum: Individual/Family $4,000/$8,000 $500 individual/$1,000 family (For new enrollees or those who add family members mid-year due to an IRS status change, the fund is prorated by enrollment month) $3,350 individual/$6,550 family $1,000 per year $3,000/$6,000 (family deductible must be met before plan benefits start to pay out) $5,000/$10,000, including amounts applied to in-network maximum amount Coordination of Benefits Those enrolled into an HSA cannot be enrolled into another medical plan. PHYSICIANS SERVICES Preventive Care Well Child Care: Annual Physical Exams Well Woman Care, including annual Pap test 65% of allowed amount, no deductible, Mammograms/ Routine Labs/ X- Rays In-Network Hearing Exam Outpatient Doctors Office Visits for illness or injury Office Visits, Primary Office Visits, Specialist 85%,after deductible Outpatient Services Surgeon Anesthesiologist Urgent Care Facility Inpatient Services Surgeon Anesthesiologist Hospital Visits, Consults EMERGENCY SERVICES Hospital Emergency Room Ambulance (if medically necessary)

2 PLAN FEATURES IN-NETWORK BENEFITS OUT-OF-NETWORK BENEFITS HOSPITAL CHARGES Pre-authorization Requirement Responsibility of provider; required for all inpatient admissions. Responsibility of member; required admissions. Pre-admission Testing Inpatient charges, semi-private room, services and supplies Outpatient Facility Charges Skilled Nursing Facility or Rehabilitation Facility (requires pre-authorization) OTHER SERVICES Lab and X-ray Services Lab or X-ray Service Charges Pathologist s or Radiologist s Fees Maternity Obstetrical Charges for pre- and post-natal care and delivery Hospital Charges Family Planning Office Visits, including Tests and Counseling Surgical Sterilization/IUDs/Diaphrams Infertility Treatment Artificial Insemination In-vitro Fertilization Outpatient Short-term Rehab (Limited to 30 Visits Per Calendar Year) Speech therapy Occupational therapy Physical therapy Chiropractic therapy Acupuncture (120 day per calendar year combined maximum in and out-of-network) (Preventive) (Non-Routine) (120 day per calendar year combined maximum in and out-of network), Lifetime Maximum of $25,000 on Infertility benefits Not Covered Infertility services are covered in-network only Not covered Mental Health & Substance Abuse Outpatient Inpatient/Intermediate Care (Pre-authorization is required for inpatient/intermediate care for both in and out-of-network) Home Health Care & Outpatient Private Duty Nursing & Hospice Care (requires preauthorization) 100 visits per calendar year Ambulance, non-emergency medically necessary transport Durable Medical Equipment (requires preauthorization for costs in excess of $1,000) Domestic Partner Coverage HSA funds are not available to domestic partners Prescription Drug Plan The prescription drug plan is a separate plan administered by Caremark. You can use your Health Savings Account Plan to pay for prescription drugs. Please see page 3. 2

3 Note: If there is no network available for specific service providers (e.g., Durable Medical Equipment, Ambulance), benefits will be paid at the in-network level. *2015 Plan Changes* In-network hearing exams now covered at IRS limits for employee maximum contributions were increased to $3350 (Individual) / $6650 (Family) Health Advocate will be the vendor for Disease Management and Nurseline for

4 2015 CAREMARK PRESCRIPTION DRUG PLAN (BENEFITS SUMMARY APPLIES TO THOSE ENROLLED IN THE UNITEDHEALTHCARE HEALTH SAVINGS ACCOUNT PLAN) PLAN FEATURES Administrator Caremark Customer Service (Coverage or Claim Questions) Rx Request Automated Mail Order Service Enrollment Qualified Prescription Drugs Retail Pharmacy: ALL PRESCRIPTIONS MUST BE FILLED IN- NETWORK Caremark Prescription Services Division (Group # NYTME) (800) (800) or online at Automatic enrollment with UnitedHealthcare Health Savings Account Plan Requires doctor s prescription, must be prescribed for FDAapproved purpose. Refer to the summary plan description for specific exclusions. Caremark National Network Combined Deductible with the Health Savings Account Plan (See Page 1) Annual Deductible Quantity Generic Drugs Preferred Brand Non-preferred brand (w no Non-preferred brand (with Quantity Generic Drugs Preferred Drugs Non-preferred brand (w no Non-Preferred brand (with Order Form Refills Preventive Drugs: covered at, no deductible Specified Chronic Drugs: bypass the deductible and go directly to the prescription drug design as outlined below. All other drugs: subject to the combined HSA deductible. Once the deductible is met, the plan design is as outlined below. Up to a 30-day supply $5 for maintenance drugs and $10 other generics Employee pays 30% co-insurance ($40 min, $100 max) Employee pays 30% co-insurance ($60 min, $150 max) Employee pays 50% co-insurance ($60 min, $150 max) Up to a 90-day supply $12.50 co-payment for maintenance drugs/$25 all other generics $100 copayment $100 copayment $200 copayment Required with original prescription Available by phone or at Caremark s website, 24 hours a day 4

5 Caremark Specialty Pharmacy and Services Call For medications prescribed for: Caremark Specialty Pharmacy provides greater convenience: Growth Hormone Deficiency 24/7 access to information via toll-free number, IVR or internet Multiple Sclerosis Personal Service: FedEx delivery when and where you need the Hepatitis B or C medication, links to support groups, foundations, data sources Arthritis Clinical Consultation: Clinicians, nurses and pharmacists Respiratory Syncytial Virus (RSV) available to answer questions, specific experience with Immune Deficiency medications and therapies Hemophilia, von Willebrand s disease, or related bleeding disorder Not available at retail pharmacies; call toll-free number Co-insurance for these medications will follow the co-insurance for either the Preferred brand or the non-preferred brand tiers Infertility Medications Lifetime Maximum of $15,000 Infertility Medications High Performance Step Therapy Program Caremark has added this program for the following class of drugs: Proton pump inhibitors, nasal steroids, sleep aids, and non-sedating antihistamines. This program means that you will be asked to try a generic before obtaining a non-generic prescription in one of the above mentioned classes. An exception will be of the nasal steroids class, which will allow Nasonex as the only preferred brand. Plan Extra The ExtraCare Savings Card-This is a key tag card, which is sent to you by Caremark, and can be used by you and your dependents at CVS locations or CVS.com to receive 20% off of select CVS brand healthcare items. You can receive this discount on items such as cough medicine, allergy relief medicines, and first-aid supplies. For a complete list, visit Also, you may use this card in place of any current CVS key tags you have by calling the number on the back of the card and having your account transferred to your new key tags Changes Addition of the Pharmacy Advisor Program- This program allows members with chronic health conditions, who fill scripts at a CVS pharmacy, to have face- to- face counseling sessions with a pharmacist about their medication(s) Generic Preventive Breast Cancer medications will be covered at due to Health Reform Please note the following about your UnitedHealthcare Health Savings Plan: As required by the Affordable Care Act, preventive care and screening for women provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) will be covered at in-network only. This includes the following additional eight categories of services: o Well-woman visits o Gestational diabetes screening o HPV DNA testing o Sexually transmitted infection counseling o HIV screening and counseling o FDA-approved contraception methods and contraceptive counseling o Breastfeeding support, supplies and counseling 5

6 o Domestic violence screening and counseling Other UnitedHealthcare Information Use this website to create a personal health record, save coverage details, view claims for yourself and enrolled dependents, find a doctor, learn about health conditions, take a Health Assessment, and to utilize free tools, quizzes and calculators. United Behavioral Health Program- A managed mental health program where you may speak with trained counselors 24-hours a day/7-days a week. To find mental health providers, visit This chart contains information on an option under the Company s Medical Plan for eligible employees. The Company retains the right to change or terminate the Plan at any time by an action of the ERISA Management Committee. The Plan is fully described in a legal plan document and a summary plan description. In all cases, the legal plan document governs. 6