Page 6 - Guaranty Home Mortgage-2022-Benefit Guide

Medical and Pharmacy Coverage

NEW! UHC Base Plan UHC Buy-Up Plan
Medical Plan Provisions HDHP/HSA Plan

Actual Member Deductible
(Individual/Family) $2,250/$4,500 $1,000/$2,000 $1,000/$2,000
Company Contribution to HRA or HSA
(Individual/Family) HSA: $750/$1,500 HRA: $4,000/$8,000 HRA: $4,000/$8,000
Annual Deductible $3,000/$6,000 $5,000/$10,000 $5,000/$10,000
(Individual/Family) (embedded)
Annual Out-of-Pocket Maximum $7,000/$14,000 $6,600/$13,200 $7,150/$14,300
(Includes Deductible)
Preventive Care Covered at 100% Covered at 100% Covered at 100%
Primary Care Provider Office Visit 50%* 50%* $30 copay
Specialist Office Visit 50%* 50%* $50 copay
Telemedicine $49 fee $49 fee Covered at 100%
X-Ray and Lab 50%* 50%* Covered at 100%
Inpatient Hospital Services 50%* 50%* 50%*
Urgent Care 50%* 50%* $50 copay
Emergency Room 50%* 50%* 50%*
Retail Pharmacy (up to a 30-day supply)
Generic $10 copay* $10 copay $10 copay
Brand Preferred $35 copay* $45 copay $45 copay
Brand Non-Preferred $70 copay* $90 copay $90 copay
*After deductible

Your payroll contributions for medical benefits are shown here.

NEW! UHC Base Plan UHC Buy-Up Plan
HDHP/HSA Plan

Coverage Level Bi-Weekly Monthly Bi-Weekly Monthly Bi-Weekly Monthly
Employee Only $17.31 $37.50 $34.62 $75.00 $46.15 $100.00
Employee + Spouse $132.69 $287.50 $265.38 $575.00 $334.62 $725.00
Employee + Child(ren) $86.54 $187.50 $173.08 $375.00 $230.77 $500.00

Family $173.08 $375.00 $346.15 $750.00 $415.38 $900.00
Benefits shown above are in-network only. Your plan offers out-of-network benefits as well. Refer to your certificate of coverage or myuhc.com for details.

6