Medical Plan Comparisons/Summary

Effective January 1, 2010

Your Coverage
Eligibility Employee. Spouse, domestic partner, eligible dependent children or domestic partner children to age 19 years,
or 24 years if full time student
Administered By United Healthcare
PLAN A PLAN B PLAN C
Benefits In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible $0 individual, $250 individual, $250 individual, $500 individual, $1,000 individual, $2,000 individual,
$0 family $500 family $500 family $1,000 family $2,000 family $4,000 family
Out of Pocket Maximum, includes deductible $0 individual, $1,250 individual, $1,500 individual, $3,000 individual, $4,000 individual, $8,000 individual,
$0 family $2,500 family $3,000 family $6,000 family $8,000 family $16,000 family
Inpatient/Outpatient Coinsurance 100% 80% 90% 70% 80% 60%
Lifetime Maximum Benefits Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited
Preventative Care Visit $0 Ded. & Coin. $0 Ded. & Coin. $0 Ded. & Coin.
Primary Care Physician Visit $15 Ded. & Coin. $20 Ded. & Coin. $30 Ded. & Coin.
Specialist Visit $15 Ded. & Coin. $20 Ded. & Coin. $40 Ded. & Coin.
Inpatient Hospital* $0 Ded. & Coin. Ded. & Coin. Ded. & Coin. Ded. & Coin. Ded. & Coin.
Outpatient Hospital* $0 Ded. & Coin. Ded. & Coin. Ded. & Coin. Ded. & Coin. Ded. & Coin.
Emergency Care $100 $100 $100 $100 $100 $100
Urgent Care Center Services $50 Ded & Coin. $50 Ded & Coin. $50 Ded & Coin.
Mental Health/Substance Abuse - Outpatient $15 Ded & Coin. $20 Ded & Coin. $40 Ded & Coin.
Mental Health/Substance Abuse - Inpatient Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin.
Rehabilitation Services - Outpatient Therapy (20 visits of each physical, $15 Ded & Coin. $20 Ded & Coin. $40 Ded & Coin.
occupational, speech, pulmonary rehabilitation, and cardiac rehabilitation
per calendar year)
Chiropractic Care $15 Ded & Coin. $20 Ded & Coin. $40 Ded & Coin.
Ambulance: Ground Transportation $100 copay $100 copay $100 copay $100 copay $100 copay $100 copay
Durable Medical Equipment ($5,000 per calendar year) 100% Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin.
Home Health Care (120 visits per calendar year) 100% Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin.
*United Healthcare notification required on “Out-of-Network” benefit. Continued on next page.
 Medical Plan Comparisons/Summary (continued)
Effective January 1, 2010

Your Coverage
PLAN A PLAN B PLAN C
Benefits In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Hospice Care (360 days during the entire time covered under plan) 100% Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin.
Infertility Services (limited to $25,000 per year)^ 100% Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin.
Injections received in a physicians office $15 Ded & Coin. $20 Ded & Coin. $30 Ded & Coin.
Maternity services* $15 $20 $40
Ded & Coin. Ded & Coin. Ded & Coin.
(for first visit only) (for first visit only) (for first visit only)
Outpatient Surgery, Diagnostic, and Therapeutic Services* 100% Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin.
Physician's Office Services $15 Ded & Coin. $20 Ded & Coin. $30/$40 Ded & Coin.
Professional Fees for Surgical and Medical Services* 100% Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin.
Skilled Nursing Facility/Inpatient Rehab Facility Services 100% Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin. Ded & Coin.
(180 days per calendar year)
Spinal Treatment $15 Ded & Coin. $20 Ded & Coin. $40 Ded & Coin.
Prescription Drugs – Same Coverge for All Plan Options
Retail Pharmacy
Generic $10
Brand Formulary $25
Brand Non-Formulary $45
Mail Order Pharmacy Administered by Medco
Generic $20
Brand Formulary $50
Brand Non-formulary $90
Employee Semi-Monthly Contributions
Employee $60.00 $52.50 $35.00
Employee +1 $115.00 $102.50 $67.50
Employee + Family $197.50 $175.00 $117.50

*United Healthcare notification required on “Out-of-Network” benefit.