Page 5 - 2022 CPI Card Benefits Guide

Medical Plan Comparison

Buy-Up PPO Plan Base PPO Plan HDHP With HSA Plan
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Deductible
Single $1,000 $4,000 $1,750 $6,000 $3,000 $5,500
Family $3,000 $12,000 $3,500 $12,000 $6,000 $11,000
Coinsurance 10% 50% 20% 50% 10% 50%
Out-of-Pocket Maximum (Includes Deductible)
Single $4,000 $6,000 $5,000 $15,000 $4,000 $7,000
Family $8,000 $18,000 $10,000 $30,000 $8,000 $14,000
Copays/Coinsurance
Premium Care Physician

/ Tier 1 Visit*
Primary Care Physician $30 50%** $35 50%** 10%** 50%**
Specialist $50 50%** $70 50%** 10%** 50%**
Non-Premium Care
Physician / Tier 2 Visit
Primary Care Physician $60 50%** $70 50%** 20%** 50%**
Specialist $100 50%** $125 50%** 20%** 50%**
Virtual Visits $30 NA $35 NA 10%** N/A
Not
Not
Not
Preventive Care Covered at covered Covered at covered Covered at covered
100%
100%
100%
Lab, X-Rays & Nuclear Medicine
Lab work 10%** 50%** 20%** 50%** 10%** 50%**
X-rays 10%** 50%** 20%** 50%** 10%** 50%**
MRI, CAT, PET & Nuclear
Medicine 10%** 50%** 20%** 50%** 10%** 50%**
Other Services
Hospital Services 10%** 50%** 20%** 50%** 10%** 50%**
Outpatient Surgery 10%** 50%** 20%** 50%** 10%** 50%**
Urgent Care $50 Copay 50%** $50 Copay 50%** 10%** 50%**
Emergency Room $200 Copay $200 Copay 10%
Prescription Drugs
No Deductible No Deductible After Deductible is Met
Copay + Copay +
difference in
difference in
Retail $10/$45/$80 cost wholesale $10/$45/$80 cost wholesale 10% 50%
& retail & retail
Copay + Copay +
difference in
difference in
Mail Order 2.5 times cost wholesale 2.5 times cost wholesale 10% 50%
retail
retail
& retail & retail
*
Tier 1 Provider: Look for the blue circle when you look up a provider on myuhc.com to get the most coverage from your plan. The blue circle
identifies physicians who meet the criteria for providing quality and cost-efficient care.
** After annual deductible.

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