Page 10 - ABM 2021 Benefit Guide RDU
P. 10
Medical and Pharmacy Benefits
UnitedHealthcare. A highlight of the plans is shown in the following table. Please note all
medical copays apply toward the out-of-pocket maximum. To locate an in-network provider, call
855.226.3456 or login to myuhc.com . The coinsurance percentage shown in the chart below
®
represents the amount the team member will pay toward the cost.
United Healthcare In-Network RDU Gold Out-of-Network In-Network RDU Bronze Out-of-Network
Calendar Year Deductible
Individual $500 $1,000 $2,700 $5,000
Family $1,000 $2,000 $5,400 $10,000
Out-of-Pocket Maximum
Individual $3,500 $5,000 $5,500 $5,500
Family $7,000 $10,000 $11,000 $11,000
Coinsurance 20% team member/ 40% team member/ 0% team member/ 0% team member/
80% plan 60% plan 100% plan 100% plan
Physician Oice Visits
Primary Care $25 copay 40% after deductible $25 copay 0% after deductible
Specialist $50 copay 40% after deductible $50 copay 0% after deductible
Virtual Visits $25 copay No coverage $25 copay No coverage
Urgent Care $75 copay 40% after deductible $75 copay 0% after deductible
Wellness/Preventive No charge 40% after deductible No charge 0% after deductible
Lab Services
Physician Oice No charge 40% after deductible No charge 0% after deductible
X-Ray/Radiology Services
Physician Oice No charge 40% after deductible No charge 0% after deductible
Hospital Services
Inpatient 20% after deductible 40% after deductible 0% after deductible 0% after deductible
Outpatient 20% after deductible 40% after deductible 0% after deductible 0% after deductible
Emergency Room $150 copay $150 copay $150 copay $150 copay
Mental Health
Inpatient 20% after deductible 40% after deductible 0% after deductible 0% after deductible
Outpatient $25 copay 40% after deductible $25 copay 0% after deductible
Substance Abuse
Inpatient 20% after deductible 40% after deductible 0% after deductible 0% after deductible
Outpatient $25 copay 40% after deductible $25 copay 0% after deductible
Prescription Drugs
Retail—Supply Limit 31-day supply 31-day supply
Tier 1 $10 copay $10 copay $10 copay $10 copay
Tier 2 $35 copay $35 copay $35 copay $35 copay
Tier 3 $60 copay $60 copay $60 copay $60 copay
Mail Order—Supply Limit 90-day supply 90-day supply
Tier 1 $25 copay N/A $25 copay N/A
Tier 2 $87.50 copay N/A $87.50 copay N/A
Tier 3 $150 copay N/A $150 copay N/A
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there
is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.
10 2021 Benefits Enrollment
UnitedHealthcare. A highlight of the plans is shown in the following table. Please note all
medical copays apply toward the out-of-pocket maximum. To locate an in-network provider, call
855.226.3456 or login to myuhc.com . The coinsurance percentage shown in the chart below
®
represents the amount the team member will pay toward the cost.
United Healthcare In-Network RDU Gold Out-of-Network In-Network RDU Bronze Out-of-Network
Calendar Year Deductible
Individual $500 $1,000 $2,700 $5,000
Family $1,000 $2,000 $5,400 $10,000
Out-of-Pocket Maximum
Individual $3,500 $5,000 $5,500 $5,500
Family $7,000 $10,000 $11,000 $11,000
Coinsurance 20% team member/ 40% team member/ 0% team member/ 0% team member/
80% plan 60% plan 100% plan 100% plan
Physician Oice Visits
Primary Care $25 copay 40% after deductible $25 copay 0% after deductible
Specialist $50 copay 40% after deductible $50 copay 0% after deductible
Virtual Visits $25 copay No coverage $25 copay No coverage
Urgent Care $75 copay 40% after deductible $75 copay 0% after deductible
Wellness/Preventive No charge 40% after deductible No charge 0% after deductible
Lab Services
Physician Oice No charge 40% after deductible No charge 0% after deductible
X-Ray/Radiology Services
Physician Oice No charge 40% after deductible No charge 0% after deductible
Hospital Services
Inpatient 20% after deductible 40% after deductible 0% after deductible 0% after deductible
Outpatient 20% after deductible 40% after deductible 0% after deductible 0% after deductible
Emergency Room $150 copay $150 copay $150 copay $150 copay
Mental Health
Inpatient 20% after deductible 40% after deductible 0% after deductible 0% after deductible
Outpatient $25 copay 40% after deductible $25 copay 0% after deductible
Substance Abuse
Inpatient 20% after deductible 40% after deductible 0% after deductible 0% after deductible
Outpatient $25 copay 40% after deductible $25 copay 0% after deductible
Prescription Drugs
Retail—Supply Limit 31-day supply 31-day supply
Tier 1 $10 copay $10 copay $10 copay $10 copay
Tier 2 $35 copay $35 copay $35 copay $35 copay
Tier 3 $60 copay $60 copay $60 copay $60 copay
Mail Order—Supply Limit 90-day supply 90-day supply
Tier 1 $25 copay N/A $25 copay N/A
Tier 2 $87.50 copay N/A $87.50 copay N/A
Tier 3 $150 copay N/A $150 copay N/A
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there
is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.
10 2021 Benefits Enrollment
