Page 6 - 2020 MAS Benefit Guide
P. 6
Medical Plan Details
UnitedHealthcare
Base Plan—Option 1 Buy-Up Plan—Option 2
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible (Embedded)*
Individual $2,500 $5,000 $1,500 $5,000
Family $5,000 $10,000 $3,000 $10,000
Out-of-Pocket Maximum
Individual $6,000 $10,000 $5,000 $10,000
Family $12,000 $20,000 $10,000 $20,000
Physician Oice Visits
Primary Care $30 copay 50% coinsurance $25 copay 50% coinsurance
Specialist $60 copay 50% coinsurance $50 copay 50% coinsurance
Wellness/Preventive
100% covered 50% coinsurance 100% covered 50% coinsurance
Urgent Care
$75 copay 50% coinsurance $75 copay 50% coinsurance
Hospital Services
Inpatient 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance
Outpatient 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance
Emergency Room $250 copay, then 20% $250 copay, then 20% $250 copay, then 20% $250 copay, then 20%
Prescription Drugs (In-Network)
Retail Mail Order Retail Mail Order
(31-day supply) (90-day supply) (31-day supply) (90-day supply)
Tier 1 $15 copay $37.50 copay $15 copay $37.50 copay
Tier 2 $35 copay $87.50 copay $35 copay $87.50 copay
Tier 3 $70 copay $175 copay $70 copay $175 copay
* Embedded: With family coverage in embedded plans, the individual deductible and out-of-pocket maximum still applies to each individual on the
plan. You can satisfy the individual limit and the plan begins covering your eligible expenses. Additionally, once a combination of family members
satisies the full family deductible and out-of-pocket maximum, the plan begins covering all family members eligible expenses.
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.
6 2020 Benefits Guide
UnitedHealthcare
Base Plan—Option 1 Buy-Up Plan—Option 2
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible (Embedded)*
Individual $2,500 $5,000 $1,500 $5,000
Family $5,000 $10,000 $3,000 $10,000
Out-of-Pocket Maximum
Individual $6,000 $10,000 $5,000 $10,000
Family $12,000 $20,000 $10,000 $20,000
Physician Oice Visits
Primary Care $30 copay 50% coinsurance $25 copay 50% coinsurance
Specialist $60 copay 50% coinsurance $50 copay 50% coinsurance
Wellness/Preventive
100% covered 50% coinsurance 100% covered 50% coinsurance
Urgent Care
$75 copay 50% coinsurance $75 copay 50% coinsurance
Hospital Services
Inpatient 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance
Outpatient 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance
Emergency Room $250 copay, then 20% $250 copay, then 20% $250 copay, then 20% $250 copay, then 20%
Prescription Drugs (In-Network)
Retail Mail Order Retail Mail Order
(31-day supply) (90-day supply) (31-day supply) (90-day supply)
Tier 1 $15 copay $37.50 copay $15 copay $37.50 copay
Tier 2 $35 copay $87.50 copay $35 copay $87.50 copay
Tier 3 $70 copay $175 copay $70 copay $175 copay
* Embedded: With family coverage in embedded plans, the individual deductible and out-of-pocket maximum still applies to each individual on the
plan. You can satisfy the individual limit and the plan begins covering your eligible expenses. Additionally, once a combination of family members
satisies the full family deductible and out-of-pocket maximum, the plan begins covering all family members eligible expenses.
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.
6 2020 Benefits Guide
