Page 6 - 2022 Chartwell Hospitality Managers

Medical Plan

United Health Care Option 1 Option 2 Option 3
Choice Plus Plan $500 Deductible $2,000 Deductible $4,000 Deductible
Member Pays Member Pays Member Pays

Out of Out of Out of
In Network In Network In Network
Network Network Network

Deductible
Individual/Family $500/$1,000 $1,000/$2,000 $2,000/$4,000 $4,000/$8,000 $4,000/$8,000 $6,000/$12,000
Out-of-Pocket Maximum:
Individual/Family $4,000/$8,000 $8,000/$16,000 $5,000/$10,000 $10,000/$20,000 $4,000/$8,000 $15,000/$30,000
(includes deductible)
Lifetime Maximum Unlimited Unlimited Unlimited

Office Visits
• Primary care $25 50%* $25 50%* 0%* 50%*
• Specialist $50 50%* $50 50%* 0%* 50%*
• Preventive care No Charge Not Covered No Charge Not Covered No Charge Not Covered

Virtual Visits $0 50%* $0 50%* $0 50%*

Chiropractor $25 50%* $25 50%* 0%* 50%*

In Patient/Outpatient
Services 20%* 50%* 20%* 50%* 0%* 50%*
$350 $350
Emergency Room $350 copay $350 copay 0%* 50%*
copay/20%* copay/*20%*

Urgent Care $50 copay 50%* $75 copay 50%* 0%* 50%*
Behavioral Treatment: $25 $25
Outpatient/Inpatient copay/20%* 50%* copay/20%* 50%* 0%* 50%*
Prescription Drugs
(Retail – 30-day supply)
Generic $10 copay $10 copay $10 copay
Preferred Brand $35 copay $35 copay $35 copay
Non-Preferred $60 copay See note** $60 copay See note** $70 copay See note**
Brand
(Mail Order – 90-day 3X Copay 3X Copay 3X Copay
supply)

*after Deductible
** If you use an out-of-network pharmacy (including mail-order), you may be responsible for any amount over the allowed amount.

Activate your myuhc.com account Download the UnitedHealthcare app
• Find the average cost of care • The UnitedHealthcare® app puts your health
• See what’s covered plan at your fingertips. Download it to:
• View claim details • Find nearby care options in your network
• Check your plan balances • View and share your health plan ID card with
• Find network providers your doctor’s office

• Video chat with a doctor 24/7