Medical

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Medical

Ulta Beauty provides medical coverage for you and your family. With different plan options available, you can choose the coverage that is right for you.

• Medical Plans – Non-Hawaii Associates

  You have two PPO plan options (PPO Plus Plan or PPO Plan) and a High Deductible Healthcare Plan option (HSA Plan) through Blue Cross Blue Shield of IL (BCBSIL). All three of these plans have the same network of doctors under BCBSIL but vary in service coverage costs and payroll deductions. Each of the plans includes a pharmacy benefit and virtual care.

  Once you've enrolled in medical coverage through BCBSIL, register for Blue Access for Members to review your claims and get additional copies of your ID card at any time. Once registered, there are additional programs and resources offered to members. To confirm or find a provider in the network, use the BCBS Physician Finder.

  Eligibility: Full-time associates (non-Hawaii)

  Provider: BCBSIL

  Enroll: https://ultabenefits.bswift.com/

  BCBSIL	PPO Plus Plan In Network	PPO Plan In Network	HSA Plan In Network
  Deductible (annual) • Per Person • Per Family	• $450 • $1,350	• $1,250 • $3,000	Non-Embedded* • $2,000 • $5,000
  Coinsurance (associate %)	10% after deductible	30% after deductible	20% after deductible
  Out-of-Pocket Max • Per Person Per Year • Per Family Per Year	• $1,750 • $5,250	• $3,000 • $9,000	• $5,000 • $10,000
  Doctor Visit	$20 copay Preventive Visits: $0	$25 copay Preventive Visits: $0	20% coinsurance after deductible Preventive Visits: $0
  Specialist Visit	$35 copay	$40 copay	20% coinsurance after deductible
  Preventive Care	$0	$0	$0
  Telemedicine	$0	$0	$0
  Inpatient Hospital	Additional $200 deductible; then 10% coinsurance	Additional $200 deductible; then 30% coinsurance	20% coinsurance after deductible
  Outpatient Hospital	Additional $100 deductible; then 10% coinsurance	Additional $100 deductible; then 10% coinsurance	20% coinsurance after deductible
  Emergency Room	$150 co-pay	$150 co-pay	20% coinsurance after deductible
  Lifetime Maximum	Unlimited	Unlimited	Unlimited
  Health Savings Account Employer Contribution (annual)	N/A	N/A	Click here for more information on a Health Savings Account $500 (associate only) $1,000 (All other coverages)

  *With a non-embedded deductible, only a family deductible applies for those covering dependents. All family members’ out-of-pocket expenses count towards the family deductible until it is met, and then they are all covered with the health plan’s usual copays or coinsurance.

  Rates and information can be found at ultabenefits.bswift.com.

• Medical Plans – Hawaii Associates

  You have two options through Hawaii Medical Service Association (HMSA): PPO or HMO. Each of the plans includes a pharmacy benefit and virtual care.

  Eligibility: Full-time Hawaii associates

  Provider: HMSA

  Enroll: https://ultabenefits.bswift.com/

  Hawaii Medical Service Association (HMSA)	PPO	HMO
  Deductible (Single/Family)	N/A	N/A
  Out-of-Pocket Max (Single/Family)	$2,500/$7,500	$2,500/$7,500
  Preventive Care	$0	$0
  Coinsurance	10% inpatient 20% outpatient	10% inpatient 20% outpatient
  Office Visit Copay (PCP/SP)	$12/$12	$20/$20
  Physical Therapy Copay	20% coinsurance	$20
  Radiology (X-Ray)	20% coinsurance	$10
  Radiology (MRI, CT Scan, etc.)	20% coinsurance	20% coinsurance
  Urgent Care Copay	$12	$20
  Emergency Room Copay	20% coinsurance	$100
  Hospital Room & Board	10% coinsurance	10% coinsurance
  Surgery	10% coinsurance (cutting) 20% coinsurance (non-cutting)	10% coinsurance (cutting) 20% coinsurance (non-cutting)

  Rates and information can be found at ultabenefits.bswift.com.