Page 3 - 2020 Wiese Benefits Guide
P. 3
2020
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\Health Ins\Summary of Beneits.
2020 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 2020 Team Member Cost/Week
TM only $35 .00 $17 .10 $14 .25
TM + Child(ren) $114 .25 $63 .00 $51 .75
TM + Spouse $122 .50 $69 .00 $60 .25
TM + Family $151 .75 $77 .75 $64 .00
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
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\Health Ins\Summary of Beneits.
2020 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 2020 Team Member Cost/Week
TM only $35 .00 $17 .10 $14 .25
TM + Child(ren) $114 .25 $63 .00 $51 .75
TM + Spouse $122 .50 $69 .00 $60 .25
TM + Family $151 .75 $77 .75 $64 .00
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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