Page 4 - Enrollment Guide
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Enrollment
UnitedHealthcare Major Medical Plan
AFV will continue to offer a medical plan administered by
Spousal Certification UnitedHealthcare. A summary of the UnitedHealthcare Plan is shown
If you enroll in the UHC Medical Plan in the table below.
and your spouse has access to their
employer-sponsored health plan Beneit In-Network Out-of-Network
they must elect coverage through Deductibles and Maximums
their employer’s plan. Spouses with Individual $1,500 $4,500
alternative employer-sponsored health Family $4,500 $13,500
coverage are not eligible to participate Out-of-Pocket calendar year maximum (includes deductible, copays,
in the UHC Medical Plan. You must and coinsurance)
recertify whether your spouse is Individual $4,500 $13,500
currently employed or not. If they are Family $13,200 $40,500
currently employed and have access to Lifetime beneit maximum Unlimited
their own employer-sponsored health
plan, you will need to remove them Covered Services
from the UHC Medical Plan. Ofice visits
Primary physician 100% after $35 copay 50% after deductible
Specialist 100% after $60 copay 50% after deductible
Preventive care 100% No copay 50% after deductible
Emergency medical care
Emergency room 100% after $250 copay 100% after $250 copay
Urgent care 100% after $50 copay 50% after deductible
Ambulance 70% after deductible 50% after deductible
Hospital services
Inpatient services 70% after deductible 50% after deductible
Outpatient services 70% after deductible 50% after deductible
Summary of Prescription Beneits
Retail (up to 31 days)
In-Network $20/$40/$60
Out-of-Network $20/$40/$60
Mail (up to 90 days)
In-Network $40/$80/$120
Out-of-Network Not covered
UHC Plan Weekly Contribution Rates
Employee $60.63
Employee + Spouse $144.00
Employee + Child(ren) $138.59
Family $156.03
4
Enrollment
UnitedHealthcare Major Medical Plan
AFV will continue to offer a medical plan administered by
Spousal Certification UnitedHealthcare. A summary of the UnitedHealthcare Plan is shown
If you enroll in the UHC Medical Plan in the table below.
and your spouse has access to their
employer-sponsored health plan Beneit In-Network Out-of-Network
they must elect coverage through Deductibles and Maximums
their employer’s plan. Spouses with Individual $1,500 $4,500
alternative employer-sponsored health Family $4,500 $13,500
coverage are not eligible to participate Out-of-Pocket calendar year maximum (includes deductible, copays,
in the UHC Medical Plan. You must and coinsurance)
recertify whether your spouse is Individual $4,500 $13,500
currently employed or not. If they are Family $13,200 $40,500
currently employed and have access to Lifetime beneit maximum Unlimited
their own employer-sponsored health
plan, you will need to remove them Covered Services
from the UHC Medical Plan. Ofice visits
Primary physician 100% after $35 copay 50% after deductible
Specialist 100% after $60 copay 50% after deductible
Preventive care 100% No copay 50% after deductible
Emergency medical care
Emergency room 100% after $250 copay 100% after $250 copay
Urgent care 100% after $50 copay 50% after deductible
Ambulance 70% after deductible 50% after deductible
Hospital services
Inpatient services 70% after deductible 50% after deductible
Outpatient services 70% after deductible 50% after deductible
Summary of Prescription Beneits
Retail (up to 31 days)
In-Network $20/$40/$60
Out-of-Network $20/$40/$60
Mail (up to 90 days)
In-Network $40/$80/$120
Out-of-Network Not covered
UHC Plan Weekly Contribution Rates
Employee $60.63
Employee + Spouse $144.00
Employee + Child(ren) $138.59
Family $156.03
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