JOHN DEERE EMPLOYEE BENEFITS - 2016 HEALTHCARE BENEFIT SUMMARY

Plan #0247 UHC CarePlusMAX 1-888-JDEERE1

BenefitIn-Network (Choice Plus)Out-of-Network

Annual Deductible
In- and Out-of-Network deductibles cross-accumulate / $2,350 for single coverage or $4,700 for family coverage per calendar year / $4,700 for single coverage or $9,400 for family coverage per calendar year
Maximum Out-of-Pocket Expense
Does not include dental, vision, or charges in excess of reasonable and customary. / $2,900 for single coverage or $5,800 for family coverage per calendar year / Unlimited
Physician Services – General
Office Visits
Hospital Visits
Surgical Procedures
Office
Outpatient
Inpatient
Maternity Care

Allergy Testing

Allergy Injections / 90% of allowed covered charge*
90% of allowed covered charge*
90% of allowed covered charge*
90% of allowed covered charge*
90% of allowed covered charge*
90% of allowed covered charge*
(For employee and spouse only)
(Dependents are not eligible)
90% of allowed covered charge*
90% of allowed covered charge* / 50% of allowed covered charge*
50% of allowed covered charge*
50% of allowed covered charge*
50% of allowed covered charge*
50% of allowed covered charge*
50% of allowed covered charge*
(For employee and spouse only)
(Dependents are not eligible)
50% of allowed covered charge*
50% of allowed covered charge*
Preventive Services**
Preventive Exam
Mammograms
Pap Tests
Well-Child Care
Immunizations
Screenings
Cholesterol
Osteoporosis
Expanded Women’s preventive health
**Based upon U.S. Preventive Services Task Force (USPSTF) guidelines and the Affordable Care Act guidelines. / 100% of allowed covered charge
100% of allowed covered charge
100% of allowed covered charge
100% of allowed covered charge
100% of allowed covered charge100% of allowed covered charge / 50% of allowed covered charge*
50% of allowed covered charge*
50% of allowed covered charge*
50% of allowed covered charge*
50% of allowed covered charge*
50% of allowed covered charge*
Hospital Services
Inpatient Care
Outpatient Care / 90% of allowed covered charge*
90% of allowed covered charge*
Pre-notification required
/ 50% of allowed covered charge*

50% of allowed covered charge*

Pre-notification required
Failure to pre-notify will result in a $300 benefit reduction
Emergency Room
Emergency Ambulance / 90% of allowed covered charge*
90% of allowed covered charge to nearest facility*
Skilled Nursing Care / 90% of allowed covered charge*
Pre-notification required
/ 50% of allowed covered charge*
Pre-notification required
Home Health Care / 90% of allowed covered charge*
Pre-notification required
/
50% of allowed covered charge*
Pre-notification required
Hospice /
90% of allowed covered charge*
Pre-notification required /
Covered in-network only
Durable Medical Equipment / 90% of allowed covered charge* / Covered in-network only
Prosthetic Devices / 90% of allowed covered charge* / Covered in-network only
Physical/Occupational/Speech Therapy / 90% of allowed covered charge*
Maximum 60 combined treatment days per calendar year in-and out-of-network / 50% of allowed covered charge*
Maximum 60 combined treatment days per calendar year in- and out-of-network
Cardiac or Pulmonary Therapy / 90% of allowed covered charge*
Maximum 36 days per calendar year in- and out-of-network / 50% of allowed covered charge*
Maximum 36 days per calendar year in- and out-of-network
Chiropractic Services / 90% of allowed covered charge*
Maximum 12 visits per calendar year in- and out-of-network / 50% of allowed covered charge*
Maximum 12 visits per calendar year in- and out-of-network
BenefitIn-Network (Choice Plus)Out-of-Network
Imaging and Laboratory Services / 90% of allowed covered charge* / 50% of allowed covered charge*
Organ Transplants
(Must use URN provider) / 90% of allowed covered charge*
(Must be approved by UHC) /

Covered in-network only

Mental Health Services
Office Visits
Inpatient Care
Outpatient Care / 90% of allowed covered charge*
90% of allowed covered charge*
90% of allowed covered charge*
(Must triage through United Behavioral Health) / 50% of allowed covered charge*
50% of allowed covered charge*
50% of allowed covered charge*
(Must triage through United Behavioral Health)
Substance Abuse Services
Office Visits
Inpatient Care
Outpatient Care / 90% of allowed covered charge*
90% of allowed covered charge*
90% of allowed covered charge*
(Must triage through United Behavioral Health) / 50% of allowed covered charge*
50% of allowed covered charge*
50% of allowed covered charge*
(Must triage through United Behavioral Health)
Prescription Drugs
31-day supply
90-day supply for maintenance drugs
(Mail order program is available) / Participating Pharmacy
90% of allowed covered for Tier 1 drugs*
90% of allowed covered for Tier 2 drugs*
90% of allowed covered for Tier 3 drugs* / Covered in-network only
Hearing (Benefit payable once every 36 mths)
Exam
Hearing Aids
Hearing Aid MgmtSvcs (HAMS) Network (where available)
Exam
Hearing Aids
(Contact UHC for a list of providers) / 100% of allowed covered charge - $70 benefit maximum*
100% of allowed covered charge - $1000 ($500 per ear) benefit maximum*
100% of allowed covered charge*
100% of allowed covered charge for pre-determined hearing aids*
Vision Care
Eye Exam
Single Vision Lens
Bifocal Vision Lens
Trifocal Vision Lens
Lenticular Vision Lens
Frame
Contact Lenses / Participating UHC Vision Provider
100% of allowed covered charge after $5 copayment for adults age 19 and over. Copay is waived for Children under age 19.
100% of allowed covered charge after $10 copayment
100% of allowed covered charge after $10 copayment.
100% of allowed covered charge after $10 copayment
100% of allowed covered charge after $10 copayment
100% of allowed covered charge after $10 copayment
100% of allowed covered charge after $50 copayment
Exam, lenses (glasses or contact) and frame – once per 24 months – combined in- and out-of-network / Non-Participating UHC Vision Provider
100% of allowed covered charge for children under age 19. $43.70 maximum reimbursement for adults age 19 and over.
$35.00 maximum reimbursement per pair
$52.50 maximum reimbursement per pair
$70.00 maximum reimbursement per pair
$87.40 maximum reimbursement per pair
$24.80 maximum reimbursement
$52.50 maximum reimbursement per pair
Exam, lenses (glasses or contact) and frame – once per 24 months – combined in- and out-of-network

Dental Services

/

Services provided through UnitedHealthcare

Coordination of Benefits

/

Non-Duplication of Benefit

Deere & Company reserves the right to suspend, amend, modify, or terminate the Plan(s) in any manner at any time, including the right to modify or eliminate any cost-sharing between the company and participants. Changes, which can be made at any time, are made by action of the company’s board of directors, or to the extent authorized by resolution of its board of directors, or by the Deere & Company Compensation Committee. In the event of a conflict between the language of the official Plan Documents and this document, the language of the official Plan Documents will control.

*Deductible applies. Allowed charge means, in order, contracted rates, reasonable and customary charges and billed charges.

This is a summary only.

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06/09/2015