2010 Unitedhealthcare Benefits Summary

  • June 2020
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2010 UnitedHealthcare Benefits Summary Deductible Coinsurance Out-of-pocket maximum Office visit (no referrals required) Urgent care visit Emergency room Prescription drug co-payment

Medical In-network: $400 per person (up to two family members) Out-of-network: $800 per person (up to two family members) In-network: 85% Out-of-network: 65% In-network: $2400 per person (up to two family members; includes deductible) Out-of-network: $4800 per person (up to two family members; includes deductible) Primary care physician: $20; specialist: $25 $35 co-pay $75 co-pay Tier 1: $20 for a 31 day supply, $40 for mail order 90 day supply Tier 2: $35 for a 31 day supply, $70 for mail order 90 day supply Tier 3: $65 for a 31 day supply, $130 for mail order 90 day supply Note: To determine which drugs are in each tier, refer to the Prescription Drug List Reference Guide on www.myuhc.com/groups/tribune

Dental Single: $50 in and out of network Family: $150 in and out of network Annual maximum $1,500 Lifetime maximum None Preventive & diagnostic care 100% Restorative care 80% Major care 50% Orthodontia 50% up to $1,500 lifetime maximum (children up to age 19) Note: If you receive services out-of-network, benefits are subject to reasonable and customary charges and balance billing. Deductible

Exam Single vision lenses Bifocals Trifocals Frames Contacts Benefit

Benefit Benefit

Vision In-network 100% after $10 co-pay 100% after $20 co-pay 100% after $20 co-pay 100% after $20 co-pay 100% after $20 co-pay 100% after $20 co-pay

Out-of-network Up to $40 Up to $40 Up to $60 Up to $80 Up to $45 Up to $105

Short-term Disability 40% of pay (employer paid) up to weekly maximum of $2,000; employee may buy additional 20% of pay up to weekly maximum of $2,000 Long-term Disability 60% of pay (employee paid) to $15,000 monthly maximum Life Insurance Basic life: 1 times pay (employer paid) Supplemental coverage: 1-8 times pay (employee paid) Spouse/Domestic partner coverage: $10,000 - $150,000; employee paid Dependent coverage: $5,000 - $25,000 per child; employee paid Note: AD&D insurance is also available to you and your dependents.

Flexible Spending Accounts (FSAs) The UHC FSA debit card can be used to pay for healthcare or dependent day care expenses. The commuter reimbursement account also will be coordinated by UnitedHealthcare in conjunction with WageWorks. The purpose of this summary is to provide highlights of Your Tribune Company Benefits plan. Eligibility and benefit payment determinations will be governed by the plan documents. In the event of a discrepancy between the information provided in this material and the plan documents, the plan documents will govern. Tribune Company reserves the right to change, amend or terminate the benefit plans at any time for any reason. Your eligibility for benefits does not guarantee continued employment at Tribune Company or any of its entities. Benefits for union-represented employees are subject to collective bargaining and the benefits summarized in this material may not currently apply. Local Human Resources or Tribune Benefits Service Center representatives can answer any questions about benefits for union-represented employees.

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