Page 3 - Wiese 2022 Benefits Guide
P. 3
2022
Benefits Guide
UMR—MEDICAL AND PRESCRIPTION
DRUG PLAN
Wiese ofers three medical plan options administered by UMR, a United Healthcare Company: Premium,
Economy, and Choice. For a detailed summary of your health beneits and coverage, please see the Summary
of Beneits documents located on People1st: Myself>My Company>Electronic Forms
2022 Medical Plan Options
Premium Plan Economy Plan Choice Plan
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $1,000 $2,000 $3,000 $6,000 $3,000 $6,000
Family $2,000 $4,000 $6,000 $12,000 $6,000 $12,000
Out-of-Pocket Maximum (includes deductible)
Individual $3,000 $6,000 $5,000 $10,000 $4,000 $8,000
Family $6,000 $12,000 $10,000 $20,000 $8,000 $16,000
Coinsurance
10% 40% 20% 50% 10% 40%
Copays
Primary Care $15 40% after $25 50% after 10% after 40% after
Physician deductible deductible deductible deductible
40% after 50% after 10% after 40% after
Specialist $35 $50
deductible deductible deductible deductible
40% after 50% after 40% after
Preventive Care Covered at 100% Covered at 100% Covered at 100%
deductible deductible deductible
Emergency $200 $200 $200 $200 10% after 10% after
Room deductible deductible
40% after 50% after 10% after 40% after
Urgent Care $50 $50
deductible deductible deductible deductible
Pharmacy
Deductible N/A $100 per person Combined with medical deductible
Tier 1 $15 $15
10% after deductible; certain
Tier 2 $30 50% (minimum $40 50% (minimum preventive medications are covered
Tier 3 $50 $40) $75 $50) at 100% with no deductible
Tier 4 20% up to $100 20% up to $100
New 2022 Team Member Cost/Week
TM only $41.00 $20.00 $16.50
TM + Child(ren) $133.25 $73.50 $60.25
TM + Spouse $148.25 $83.50 $73.00
TM + Family $184.50 $94.25 $77.50
Notes: If your spouse has coverage available through his/her employer but chooses not to enroll in that plan as their primary insurance, you will be
subject to an additional $60 per week surcharge.
These rates do not relect any wellness program credits or surcharges
3
Benefits Guide
UMR—MEDICAL AND PRESCRIPTION
DRUG PLAN
Wiese ofers three medical plan options administered by UMR, a United Healthcare Company: Premium,
Economy, and Choice. For a detailed summary of your health beneits and coverage, please see the Summary
of Beneits documents located on People1st: Myself>My Company>Electronic Forms
2022 Medical Plan Options
Premium Plan Economy Plan Choice Plan
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $1,000 $2,000 $3,000 $6,000 $3,000 $6,000
Family $2,000 $4,000 $6,000 $12,000 $6,000 $12,000
Out-of-Pocket Maximum (includes deductible)
Individual $3,000 $6,000 $5,000 $10,000 $4,000 $8,000
Family $6,000 $12,000 $10,000 $20,000 $8,000 $16,000
Coinsurance
10% 40% 20% 50% 10% 40%
Copays
Primary Care $15 40% after $25 50% after 10% after 40% after
Physician deductible deductible deductible deductible
40% after 50% after 10% after 40% after
Specialist $35 $50
deductible deductible deductible deductible
40% after 50% after 40% after
Preventive Care Covered at 100% Covered at 100% Covered at 100%
deductible deductible deductible
Emergency $200 $200 $200 $200 10% after 10% after
Room deductible deductible
40% after 50% after 10% after 40% after
Urgent Care $50 $50
deductible deductible deductible deductible
Pharmacy
Deductible N/A $100 per person Combined with medical deductible
Tier 1 $15 $15
10% after deductible; certain
Tier 2 $30 50% (minimum $40 50% (minimum preventive medications are covered
Tier 3 $50 $40) $75 $50) at 100% with no deductible
Tier 4 20% up to $100 20% up to $100
New 2022 Team Member Cost/Week
TM only $41.00 $20.00 $16.50
TM + Child(ren) $133.25 $73.50 $60.25
TM + Spouse $148.25 $83.50 $73.00
TM + Family $184.50 $94.25 $77.50
Notes: If your spouse has coverage available through his/her employer but chooses not to enroll in that plan as their primary insurance, you will be
subject to an additional $60 per week surcharge.
These rates do not relect any wellness program credits or surcharges
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