Page 3 - 2022 01 Benefits Guide Murata Flipbook Final 6.14.22

Medical Plan Summary – UMR/UHC
PPO High Deductible
* After deductible
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** No deductible In-network Out-of-network 1 In-network Out-of-network
Annual Deductible
Per person $1,500 $3,000 $3,000 $6,000
Per family $3,000 $6,000 $6,000 $12,000
Annual Out-of- (Includes deductible and copays²) (Includes deductible)
Pocket Max
Per person $5,850 $11,700 $6,000 $12,000
Per family $11,700 $23,400 $12,000¹ $24,000

Doctor’s Office Visit
Preventive Care 100%** 100%** 100%** 100%**

Primary Care $35 copay** 60%* 80%* 60%*

Physician Specialist $45 copay** 60%* 80%* 60%*

Urgent Care 100% after $55 60%* 80%* 60%*
copay

Emergency Room $150 copay + $150 copay + 80%* 80%*
Visit deductible deductible
+ coinsurance + coinsurance
$250 copay + $250 copay +

Inpatient hospitals deductible deductible 80%* 60%*
+ coinsurance + coinsurance

Outpatient hospitals 80%* 60%* 80%* 60%*

PPO High Deductible
*Bi-weekly
Deductions Non- Wellness Wellness Non- Wellness Wellness
Wellness 1X 2X Wellness 1X 2X

Employee Only $61.01 $39.86 N/A $46.93 $25.78 N/A

Employee + Spouse $164.39 $143.24 $122.08 $110.84 $89.69 $68.53

Employee + $152.41 $131.26 N/A $96.94 $75.79 N/A
Child(ren)

Family $257.49 $236.34 $215.18 $182.95 $161.80 $140.64

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