Retiree_Benefits_MWAA | Page 4

MEDICAL BENEFITS: INDIVIDUALS UNDER AGE 65 AND NOT MEDICARE ELIGIBLE
You have three medical options from which to choose. The options cover the same medical services, but in different ways. These options are only available to you or your covered dependents under the age of 65 and not eligible for Medicare.
BENEFITS YOU’ LL RECEIVE
FEATURE
UNITEDHEALTHCARE CHOICE PLUS
UNITEDHEALTHCARE CHOICE
KAISER PERMANENTE HMO
IN-NETWORK OUT-OF-NETWORK IN-NETWORK IN-NETWORK
Calendar year deductible
Retiree Only Retiree + Child( ren) Retiree + spouse Family
$ 300 $ 600 $ 600 $ 600
$ 750 $ 1,500 $ 1,500 $ 1,500
$ 200 $ 200 $ 200 $ 200
None
Annual out-of-pocket maximums
Medical expenses
Retiree Only Retiree + Child( ren) Retiree + spouse Family
$ 2,000 $ 4,000 $ 4,000 $ 4,000
$ 5,000 $ 10,000 $ 10,000 $ 10,000
$ 2,000 $ 4,000 $ 4,000 $ 4,000
$ 2,250 $ 4,500 $ 4,500 $ 4,500
Prescription expenses
Retiree Only Retiree + Child( ren) Retiree + spouse Family
$ 2,500 $ 5,000 $ 5,000 $ 5,000
n / a
$ 2,500 $ 5,000 $ 5,000 $ 5,000
n / a
Office visits
Primary Care Physician
$ 35 copay
Plan pays 60 %
after deductible
Specialist
$ 40 copay
Plan pays 60 %
after deductible
$ 20 copay $ 20 copay($ 0 copay: children < 5 for non-specialist visit)
$ 25 copay $ 25 copay
Virtual office visit $ 10 copay N / A $ 5 copay No copay Referral to specialist required No No No Yes Preventive care, diagnostics and surgery
Preventive care, Well child care, Adult physical, Routine OB / GYN, Mammogram, Cancer screening
No copay Plan pays 60 % after deductible
No copay
No copay
Diagnostic services, lab & X-ray
Plan pays 90 % after deductible
Plan pays 60 % after deductible
Plan pays 100 % deductible does not apply
No copay
Outpatient surgery Plan pays 90 % after deductible
Plan pays 60 % after deductible
$ 50 copay after deductible
$ 25 copay
Inpatient surgery Plan pays 90 % after deductible
Plan pays 60 % after deductible
$ 100 copay per admission
$ 250 copay per admission
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