Page 13 - Brady Corporation 2021 Annual Benefits California
P. 13
Brady Benefits Guide
Medical Plan Details
UnitedHealthcare UnitedHealthcare Kaiser
Medical Plan
HMO
Details Preferred Provider Organization (PPO) High Deductible Health Plan (HDHP) In-Network Only
In-Network
Out-of-Network
Out-of-Network
In-Network
Calendar Year Deductible
Individual $750 $1,500 $1,500 $3,000 $250
Family $1,500 $3,000 $3,000 $6,000 $500
Out-of-Pocket Maximum (includes deductible)
Individual $3,500 $7,000 $4,500 $9,000 $3,000
Family $7,000 $14,000 $9,000 $18,000 $6,000
Physician Oice Visits
Preventive Care Covered at 100% 50% after deductible Covered at 100% 50% after deductible Covered at 100%
Primary Care Visit 20% after deductible 50% after deductible 15% after deductible 50% after deductible $10 copay per visit
$50 copay per $50 copay per
Urgent Care visit and 20% after visit and 20% after 15% after deductible 15% after deductible $10 copay per visit
deductible deductible
Hospital Services
$250 copay per 50% coinsurance 15% coinsurance 50% coinsurance 10% coinsurance
Inpatient admission and 20% per admission after per admission after per admission after per admission after
coinsurance after
deductible deductible deductible deductible deductible
Emergency Room $150 copay and 20% $150 copay and 20% 15% after deductible 15% after deductible 10% coinsurance
after deductible
after deductible
Prescription Drugs
Generic 20% after deductible* 20% coinsurance* 15% coinsurance 15% coinsurance $10 copay
Preferred Brand
Formulary 30% after deductible* 30% coinsurance* 15% coinsurance 15% coinsurance $30 copay
Non-Preferred 40% after deductible* 40% coinsurance* 15% coinsurance 15% coinsurance $30 copay
Brand Formulary
Mail Order
Generic 20% after deductible* 20% coinsurance* 15% coinsurance 15% coinsurance $20 prescription
Preferred Brand 30% after deductible* 30% coinsurance* 15% coinsurance 15% coinsurance $60 prescription
Formulary
Non-Preferred 40% after deductible* 40% coinsurance* 15% coinsurance 15% coinsurance $60 prescription
Brand Formulary
Specialty medications are covered under the Specialty medications are covered under the
Specialty above categories, depending on the speciic above categories, depending on the speciic 20% coinsurance
drug drug
*$100 individual deductible, $200 family deductible applies
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.
Employee Monthly Medical Contributions
Kaiser HMO
Monthly Cost UnitedHealthcare PPO UnitedHealthcare HDHP (Employees in CA only)
You Pay Brady Pays You Pay Brady Pays You Pay Brady Pays
Employee Only $211.78 $493.00 $113.17 $580.43 $130.92 $391.89
Employee and Spouse $480.66 $1,001.68 $265.98 $1,188.54 $387.07 $757.88
Employee and Child(ren) $334.36 $929.63 $173.95 $1,078.59 $348.23 $645.10
Family $649.08 $1,590.18 $343.14 $1,811.54 $537.28 $1,052.05
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Medical Plan Details
UnitedHealthcare UnitedHealthcare Kaiser
Medical Plan
HMO
Details Preferred Provider Organization (PPO) High Deductible Health Plan (HDHP) In-Network Only
In-Network
Out-of-Network
Out-of-Network
In-Network
Calendar Year Deductible
Individual $750 $1,500 $1,500 $3,000 $250
Family $1,500 $3,000 $3,000 $6,000 $500
Out-of-Pocket Maximum (includes deductible)
Individual $3,500 $7,000 $4,500 $9,000 $3,000
Family $7,000 $14,000 $9,000 $18,000 $6,000
Physician Oice Visits
Preventive Care Covered at 100% 50% after deductible Covered at 100% 50% after deductible Covered at 100%
Primary Care Visit 20% after deductible 50% after deductible 15% after deductible 50% after deductible $10 copay per visit
$50 copay per $50 copay per
Urgent Care visit and 20% after visit and 20% after 15% after deductible 15% after deductible $10 copay per visit
deductible deductible
Hospital Services
$250 copay per 50% coinsurance 15% coinsurance 50% coinsurance 10% coinsurance
Inpatient admission and 20% per admission after per admission after per admission after per admission after
coinsurance after
deductible deductible deductible deductible deductible
Emergency Room $150 copay and 20% $150 copay and 20% 15% after deductible 15% after deductible 10% coinsurance
after deductible
after deductible
Prescription Drugs
Generic 20% after deductible* 20% coinsurance* 15% coinsurance 15% coinsurance $10 copay
Preferred Brand
Formulary 30% after deductible* 30% coinsurance* 15% coinsurance 15% coinsurance $30 copay
Non-Preferred 40% after deductible* 40% coinsurance* 15% coinsurance 15% coinsurance $30 copay
Brand Formulary
Mail Order
Generic 20% after deductible* 20% coinsurance* 15% coinsurance 15% coinsurance $20 prescription
Preferred Brand 30% after deductible* 30% coinsurance* 15% coinsurance 15% coinsurance $60 prescription
Formulary
Non-Preferred 40% after deductible* 40% coinsurance* 15% coinsurance 15% coinsurance $60 prescription
Brand Formulary
Specialty medications are covered under the Specialty medications are covered under the
Specialty above categories, depending on the speciic above categories, depending on the speciic 20% coinsurance
drug drug
*$100 individual deductible, $200 family deductible applies
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.
Employee Monthly Medical Contributions
Kaiser HMO
Monthly Cost UnitedHealthcare PPO UnitedHealthcare HDHP (Employees in CA only)
You Pay Brady Pays You Pay Brady Pays You Pay Brady Pays
Employee Only $211.78 $493.00 $113.17 $580.43 $130.92 $391.89
Employee and Spouse $480.66 $1,001.68 $265.98 $1,188.54 $387.07 $757.88
Employee and Child(ren) $334.36 $929.63 $173.95 $1,078.59 $348.23 $645.10
Family $649.08 $1,590.18 $343.14 $1,811.54 $537.28 $1,052.05
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