Page 5 - Guide
P. 5
UnitedHealthcare (UHC) Pharmacy Program
Major Medical Plan Enhancements
Beginning on January 1, 2 new
pharmacy programs will go into
PPO CDHP effect.
Out-of-
Out-of-
Beneit In-Network Network In-Network Network
Deductibles and Maximums First, through the mail service
member select program, you will
Individual $1,500 $4,500 $2,600 $8,000 be required to ill maintenance
Family $4,500 $13,500 $5,200 $16,000 drugs using UHC’s home delivery
Out-of-Pocket Calendar Year Maximum (includes deductible, copays, and
coinsurance) mail service, OptumRx. This
Individual $4,500 $13,500 $6,550 $16,000 program will require members
Family $13,200 $40,500 $13,100 $32,000 with maintenance medications
Lifetime beneit Unlimited Unlimited Unlimited to participate in the OptumRx
maximum mail service. After 2 ills at a
Covered Services retail pharmacy, you must move
Ofice Visits your maintenance prescriptions
Primary physician 100% after 80% after to OptumRx; however, you can
$35 copay deductible
Specialist 100% after 80% after disenroll from the program at
$60 copay 50% after deductible 50% after any time by calling the number
deductible
deductible
Preventive care 100% no 100% no on your member ID card. When
copay copay/no you move to OptumRx, you will
deductible receive a 3-month supply of your
Emergency Medical Care medication. The purpose of this
Emergency room 100% after 100% after 80% after
$250 copay $250 copay deductible program is to help you receive
Urgent care 100% after 50% after 80% after 50% after your maintenance drugs more
$50 copay deductible deductible deductible easily and at a lower cost. You will
Ambulance 70% after 50% after 80% after be notiied by UnitedHealthCare
deductible deductible deductible if you are currently taking a
Hospital Services maintenance drug which will
Inpatient services 70% after 50% after 80% after 50% after need to be illed through the mail
Outpatient services deductible deductible deductible deductible
Prescription Beneits service member select program.
Retail (up to 31 days) The second program is the step
In-network $20/$40/$60 80% after deductible therapy program, which helps you
Out-of-network $20/$40/$60
Mail (up to 90 days) ind less expensive but equally
In-network $40/$80/$120 80% after deductible effective medications before you
Out-of-network Not covered Not covered select more expensive non-
preferred medications.
UHC Plan Weekly Contribution Rates
PPO CDHP* Company Contribution
Employee $64.35 $48.51 $500
Employee + spouse $157.10 $132.96 $750
Employee + child(ren) $151.20 $128.26 $750
Family $170.23 $143.36 $750
* Employees who enroll in the CDHP will be provided with seed money based on the tier of
coverage elected.
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Major Medical Plan Enhancements
Beginning on January 1, 2 new
pharmacy programs will go into
PPO CDHP effect.
Out-of-
Out-of-
Beneit In-Network Network In-Network Network
Deductibles and Maximums First, through the mail service
member select program, you will
Individual $1,500 $4,500 $2,600 $8,000 be required to ill maintenance
Family $4,500 $13,500 $5,200 $16,000 drugs using UHC’s home delivery
Out-of-Pocket Calendar Year Maximum (includes deductible, copays, and
coinsurance) mail service, OptumRx. This
Individual $4,500 $13,500 $6,550 $16,000 program will require members
Family $13,200 $40,500 $13,100 $32,000 with maintenance medications
Lifetime beneit Unlimited Unlimited Unlimited to participate in the OptumRx
maximum mail service. After 2 ills at a
Covered Services retail pharmacy, you must move
Ofice Visits your maintenance prescriptions
Primary physician 100% after 80% after to OptumRx; however, you can
$35 copay deductible
Specialist 100% after 80% after disenroll from the program at
$60 copay 50% after deductible 50% after any time by calling the number
deductible
deductible
Preventive care 100% no 100% no on your member ID card. When
copay copay/no you move to OptumRx, you will
deductible receive a 3-month supply of your
Emergency Medical Care medication. The purpose of this
Emergency room 100% after 100% after 80% after
$250 copay $250 copay deductible program is to help you receive
Urgent care 100% after 50% after 80% after 50% after your maintenance drugs more
$50 copay deductible deductible deductible easily and at a lower cost. You will
Ambulance 70% after 50% after 80% after be notiied by UnitedHealthCare
deductible deductible deductible if you are currently taking a
Hospital Services maintenance drug which will
Inpatient services 70% after 50% after 80% after 50% after need to be illed through the mail
Outpatient services deductible deductible deductible deductible
Prescription Beneits service member select program.
Retail (up to 31 days) The second program is the step
In-network $20/$40/$60 80% after deductible therapy program, which helps you
Out-of-network $20/$40/$60
Mail (up to 90 days) ind less expensive but equally
In-network $40/$80/$120 80% after deductible effective medications before you
Out-of-network Not covered Not covered select more expensive non-
preferred medications.
UHC Plan Weekly Contribution Rates
PPO CDHP* Company Contribution
Employee $64.35 $48.51 $500
Employee + spouse $157.10 $132.96 $750
Employee + child(ren) $151.20 $128.26 $750
Family $170.23 $143.36 $750
* Employees who enroll in the CDHP will be provided with seed money based on the tier of
coverage elected.
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