Page 3 - Wiese 2021 Benefits Guide
P. 3
Wiese Benefits Enrollment
UMR—Medical and Prescription Drug Plan
Wiese offers 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 the network W Drive:
W:\HR Forms and Information\Health Ins Info\Summary Plan Documents.
2021 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
Specialist $35 40% after $50 50% after 10% after 40% after
deductible deductible deductible deductible
Preventive Care Covered at 40% after Covered at 50% after Covered at 40% after
100% deductible 100% deductible 100% deductible
Emergency Room $200 $200 $200 $200 10% after 10% after
deductible deductible
Urgent Care $50 40% after $50 50% after 10% after 40% after
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 2021 Team Member Cost/Week
TM only $36.75 $17.95 $14.95
TM + Child(ren) $119.95 $66.15 $54.35
TM + Spouse $134.75 $75.90 $66.27
TM + Family $166.90 $85.55 $70.40
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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UMR—Medical and Prescription Drug Plan
Wiese offers 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 the network W Drive:
W:\HR Forms and Information\Health Ins Info\Summary Plan Documents.
2021 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
Specialist $35 40% after $50 50% after 10% after 40% after
deductible deductible deductible deductible
Preventive Care Covered at 40% after Covered at 50% after Covered at 40% after
100% deductible 100% deductible 100% deductible
Emergency Room $200 $200 $200 $200 10% after 10% after
deductible deductible
Urgent Care $50 40% after $50 50% after 10% after 40% after
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 2021 Team Member Cost/Week
TM only $36.75 $17.95 $14.95
TM + Child(ren) $119.95 $66.15 $54.35
TM + Spouse $134.75 $75.90 $66.27
TM + Family $166.90 $85.55 $70.40
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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