Page 5 - Lanter Delivery Systems 2021 Benefits Guide

Lanter Delivery Systems, LLC Benefits Enrollment Guide

Medical Plan

PPO Plan HSA Plan
In-Network In-Network
Calendar Year Deductible
Individual $1,750 $3,000
Family $3,500 $6,000
Out-of-Pocket Maximum (includes deductible)
Individual $6,500 $6,550
Family $13,000 $13,100
Hospital Services
Inpatient Ded then 80% Ded then 80%
Outpatient Ded then 80% Ded then 80%
Emergency Room $300 copay Ded then 80%
Oice Visits
Preventive Care 100% covered 100% covered
Primary Care $35 copay Ded then 80%
Specialist $70 copay Ded then 80%
Virtual Visit $20 copay Ded then 80%
Chiropractic Care (20 visit max) $35 copay Ded then 80%
Urgent Care $100 copay Ded then 80%
Prescription Drugs
Retail—Supply Limit of 30 Days
Tier 1 $15 copay Ded then 80%**
Tier 2 $40 copay Ded then 80%**
Tier 3 $75 copay Ded then 80%**
Mail Order—Supply Limit of 90 days
Tier 1 $37.50 copay Ded then 80%**
Tier 2 $100 copay Ded then 80%**
Tier 3 $187.50 copay Ded then 80%**

This is a summary of your in-network beneit coverage. Full coverage and out-of-network details are available in the policy or certiicate of coverage.
* If you purchase a Prescription Drug from a Non-Network Pharmacy, you are responsible for any diference between the Non-Network Pharmacy
charges and the amount UHC would have paid for the same drug at a Network Pharmacy.
** Preventive medications will be covered at 100% on the HSA Plan. They are not subject to a deductible or coinsurance. Contact Human Resources for
the Preventive Drug List.

Premium Per Pay Period

PPO Plan HSA Plan
Employee (EE) $29.50 $18.50
Employee and Spouse $86.75 $60.15
Employee and Child(ren) $62.00 $43.50
Family $130.50 $94.00

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