Us Apple Plus Ppo Feb2019 en 1

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2019

Apple Plus PPO Overview


The summary below highlights some of the features of the Apple Plus PPO Plan.
For comprehensive details about the plan, see the Apple Benefits Book.
Plan Name Apple Plus PPO
Network Type In-Network Out-of-Network
When you use a doctor in the UnitedHealthcare Preferred Provider Organization (PPO)
network (or the Harvard Pilgrim providers if you live in MA, ME or NH) for office visits,
the Apple Plus PPO Plan pays 100% for eligible charges after a $20 copayment.
Specialist visits (chiropractor, physical therapist, dermatologist, cardiologist, etc.)
require a $30 copayment.
You may receive care from any provider, however, benefits from a non-PPO provider
are only payable at 70% of Eligible Expenses. Utilizing a provider from the PPO network
Overview will ensure a higher payment and will save you and Apple money.
To ensure treatment meets UHC’s clinical guidelines for coverage, you may be required
to obtain Prior Authorization for complex health services, such as for any surgery,
hospitalization, clinical trials and etc..
All of the coverage percentages noted below are based on UHC’s definition of Eligible
Expenses. Eligible Expenses for PPO providers are based on negotiated rates, while non
PPO providers are based on various data resources.
How the Plan Works
$300 per individual or up to a combined $600 per individual up to a combined
maximum of $900 with two or more maximum of $1,800 with two or more
Plan Year Deductible dependents dependents
Separate deductibles for in- and out-of- Separate deductibles for in- and out-of-
network services will cross apply network services will cross apply
Office visit and prescription copays vary Copays not applicable for out-of-network
Copay
based on type of provider and prescription providers, except for prescriptions
Plan pays 90% after deductible, except Plan pays 70% after deductible, except
Coinsurance
where noted below where noted below
$2,000 per individual $4,000 per individual
$4,000 combined maximum when covering $8,000 combined maximum when covering
dependent(s) dependent(s)
Separate maximums for in- and out-of- Separate maximums for in- and out-of-
Annual Out-of-Pocket Maximum network services will cross apply network services will cross apply
Once your portion of medical and Once your portion of medical and
prescription costs reaches the Annual Out- prescription costs reaches the Annual Out-
of-Pocket Maximum, the plan pays 100% of-Pocket Maximum, the plan pays 100% of
of eligible expenses. eligible expenses.
Preventive Care
Well Baby/Child Care Visit
Immunizations
Routine Physical Exam 100% (no deductible) 70% (no deductible)
Routine Gynecological Exam
Routine Mammography
Doctors and Other Providers
$20 copay 70% after deductible
Doctor's Office Visit
UHC Virtual Visits: $10 copay UHC Virtual Visits: Not covered
Specialist Office Visit $30 copay 70% after deductible

03/04/19 1 2019 Apple Plus PPO Overview


2019 Apple Plus PPO Overview
The summary below highlights some of the features of the Apple Plus PPO Plan.
For comprehensive details about the plan, see the Apple Benefits Book.
Plan Name Apple Plus PPO
Network Type In-Network Out-of-Network
Non-hospital X-ray and
90% after deductible 70% after deductible
Lab Services
$30 copay (billed with an office visit) 70% after deductible
Therapies: Physical, Occupational,
Includes services related to developmental Includes services related to developmental
Speech Therapy (Restorative Only)
delays delays
Chiropractic Services /
$30 copay (billed with an office visit) 70% after deductible
Spinal Manipulation
Acupuncture $30 copay (billed with an office visit) 70% after deductible
Emergency Care
Hospital Emergency 90% after deductible
Non Emergency 50% after deductible 50% after deductible
Ambulance (for medically necessary
90% after deductible
services)
Hospital
Inpatient Hospitalization - room &
board and other charges related to 90% after deductible 70% after deductible
a hospital stay
Outpatient Hospitalization 90% after deductible 70% after deductible
Diagnostic Lab & X-ray
90% after deductible 70% after deductible
while Hospitalized
Other Medical Care
$30 copay (billed with an office visit)
Allergy testing and/or injections billed
Allergy Treatment 70% after deductible
without an office visit, 90% after
deductible
Durable Medical Equipment 90% after deductible 70% after deductible
Coverage may include Assisted Reproductive Technology (ART) and coverage for in vitro
fertilization (IVF), gamete intrafallopian transfer (GIFT) and zygote intrafallopian
transfer (ZIFT); embryo transport; donor ovum and semen and related costs, including
Infertility Coverage collection, preparation and storage of; artificial insemination and cryopreservation; and
related prescription drugs.
Combined medical and prescription lifetime maximum for in- and out-of-network
services.
$30 copay (billed with an office visit)
All other services outside an office visit: 70% after deductible
Infertility Treatment 90% after deductible Up to a $20,000 lifetime maximum
Up to a $20,000 lifetime maximum
Hospice 90% after deductible 70% after deductible
Skilled Nursing 90% after deductible 70% after deductible
Mental Health / Chemical Dependency
Office visit: $20 copay Office visit: 70% aker deduclble
Doctor's Office Visit
Telemedicine visit: $10 copay Telemedicine visit: Not covered
All other outpatient / inpatient
90% after deductible 70% after deductible
services
Prescription Drugs
03/04/19 2 2019 Apple Plus PPO Overview
2019 Apple Plus PPO Overview
The summary below highlights some of the features of the Apple Plus PPO Plan.
For comprehensive details about the plan, see the Apple Benefits Book.
Plan Name Apple Plus PPO
Network Type In-Network Out-of-Network
Tier 1 (lowest-cost drug) $10 copay
Tier 2 (mid-range cost drug) $30 copay
Tier 3 (highest-cost drug) $50 copay
At the Pharmacy
(up to the required dosage for 30-days)

90-day fills available for 3x copay


Speciality Pharmacy drugs at Subject to above Tier level copays
Not applicable
Pharmacy or Mail order (up to a 30-day supply)
2x pharmacy copays
Mail order Not applicable
(up to a 90-day supply)
Employee Assistance Program
You and your family members can get up to 8 free sessions, per counseling topic, in a
12-month period. You can also get unlimited telephonic assistance for financial
guidance and legal consultalons, along with guidance and referrals for elder care,
parenlng, childcare and even pet care needs.
ComPsych: EAP
Assistance available 24 hours a day, seven days a week.
US: 844-862-0889
International: +1 312-595-0074
Before-Tax Cost
Per Pay Period: $42.74
Employee Per Month: $92.60
Per Year: $1,111.24
Per Pay Period: $138.08
Employee + Spouse or Domestic
Per Month: $299.18
Partner
Per Year: $3,590.08
Per Pay Period: $99.91
Employee + Child(ren) Per Month: $216.48
Per Year: $2,597.66
Per Pay Period: $185.98
Employee + Family Per Month: $402.96
Per Year: $4,835.48

The Medical Plan(s) Chart highlights commonly used services and generally indicates how you and a medical plan will cover
medical expenses you and/or your enrolled dependents incur. Benefits are provided for covered services that are medically
necessary unless otherwise indicated. Some services are subject to annual or lifetime limits. This chart does not reflect all
covered services, plan exclusions, limitations, or restrictions. It is not a contract or guarantee of coverage. See the Apple
Benefits Book for more information.

03/04/19 3 2019 Apple Plus PPO Overview

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