Medical Plan Summary: PPO Core Plan

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1 Medical Plan Summary: PPO Core Plan Healthcare is one of the most important and necessary parts of your benefit package. The following is a summary of our benefit plan. For a more detailed explanation of benefits, please refer to your Summary Plan Description and Summary of Benefits and Coverage (SBC). PPO CORE PLAN- BENEFIT PLAN Benefits and Enrollment Guide

2 Medical Plan Summary: PPO Core Plan PPO CORE PLAN- BENEFIT PLAN 008 CONTINUED 2017 Benefits and Enrollment Guide 5

3 Medical Plan Summary: PPO Buy-Up Plan Healthcare is one of the most important and necessary parts of your benefit package. The following is a summary of our benefit plan. For a more detailed explanation of benefits, please refer to your Summary Plan Description and Summary of Benefits and Coverage (SBC). PPO BUY-UP PLAN- BENEFIT PLAN Benefits and Enrollment Guide

4 Medical Plan Summary: PPO Buy-Up Plan PPO BUY-UP PLAN- BENEFIT PLAN 009 CONTINUED 2017 Benefits and Enrollment Guide 7

5 Medical Plan Summary: HSA Healthcare is one of the most important and necessary parts of your benefit package. The following is a summary of our benefit plan. For a more detailed explanation of benefits, please refer to your Summary Plan Description and Summary of Benefits and Coverage (SBC). HIGH DEDUCTIBLE HEALTH PLAN (HDHP) SUMMARY OF BENEFITS DEDUCTIBLES & MAXIMUMS DOMESTIC NETWORK UNC Providers IN-NETWORK SERVICES UHC Choice Plus Providers NON-NETWORK SERVICES Out-of-Network Providers Lifetime Benefit Maximum Unlimited Unlimited Unlimited Annual Deductible $1,500 Single $3,000 Family $2,750 Single $5,500 Family $3,000 Single $6,000 Family Member Coinsurance 15% 25% 35% Out-of-Pocket Maximum Includes Calendar Year Deductible & Member Coinsurance $3,000 Single $6,000 Family $5,000 Single $10,000 Family $5,000 Single $10,000 Family THE DEDUCTIBLE AND OUT-OF-POCKET MAX AMOUNTS FOR THE DOMESTIC NETWORK (UNC PROVIDERS) AND UHC CHOICE PLUS PROVIDERS CROSS-FEED. PREVENTIVE CARE & OFFICE VISITS Physician Office Visit Primary Care & Specialist Preventive Office Visit Primary Care or Specialist Covered at 100% Covered at 100% Well Baby Office Visit Covered at 100% Covered at 100% Routine Lab & X-rays Primary Care or Specialist Covered at 100% Covered at 100% Vision Care Diagnostic visits only Covered at 100% Covered at 100% Covered at 100% Prenatal Care Does not include Sonograms Postnatal Care INPATIENT & OUTPATIENT SERVICES Inpatient Facility Services Inpatient Physician Charges Outpatient Hospital & Surgery Services Outpatient Hospital Physician & Surgeon Charges DIAGNOSTIC SERVICES Outpatient Hospital Lab and X-rays Charges Independent Clinical Lab Facilities Outpatient Advanced Imaging (MRI, MRA, CT, CAT Scan) PET Scans Covered at 100% Covered at 100%. Note: Surgery is excluded. Note: Surgery is excluded Benefits and Enrollment Guide

6 Medical Plan Summary: HSA SUMMARY OF BENEFITS URGENT CARE & EMERGENCY SERVICES Urgent Care Includes Lab & X-ray & Physician Charges Emergency Room Facility Services & Physician Charges MENTAL HEALTH/SUBSTANCE DEPENDENCY Inpatient Facility Services Inpatient Physician Charges Outpatient Hospital Services Outpatient Hospital Physician Charges Physician Office Visit Primary Care providers Specialist Office Visit OTHER SERVICES Chiropractic Care 30 Visits per Calendar Year combined for all tier levels Durable Medical Equipment Occupational & Physical Therapy 30 Visits per Calendar Year for Occupational Therapy combined for all tier levels 30 Visits per Calendar Year for Physical Therapy combined for all tier levels Speech Therapy 30 Visits/Plan Year combined for all tier levels Infertility Treatment PHARMACY INFORMATION Prescription Drugs Member Cost Share Generic Preferred Brand Non-Preferred Brand Specialty Preventive Medications DOMESTIC NETWORK UNC Providers Benefit varies based on the facility in which it is performed. Lifetime benefit maximum of $7,500. UNC In-house Pharmacies 30-day Supply Covered at 100%, Deductible Waived UNC In-house Pharmacies 60-day Supply IN-NETWORK SERVICES UHC Choice Plus Providers Benefit varies based on the facility in which it is performed. Lifetime benefit maximum of $7,500. UNC In-house Pharmacies Mail Order 90-day Supply NON-NETWORK SERVICES Out-of-Network Providers Benefit varies based on the facility in which it is performed. Lifetime benefit maximum of $7,500. Retail Pharmacies 30-day Supply Covered at 70% after No coverage No Coverage No Coverage Covered at 100%, Deductible Waived Covered at 100%, Deductible Waived Covered at 80% or 70% (dependent on medication) after 2017 Benefits and Enrollment Guide 9