Page 7 - Zenoss, Inc 2022 Flipbook

Medical and pharmacy coverage –

UnitedHealthcare

Buy Up Plan – Core Plan – HDHP with HSA –
Choice Plus Network Choice Network Choice Network
Out-of- Out-of- Out-of-
Medical Plan Provisions In-Network Network In-Network Network In-Network Network
Deductible per Calendar Year $1,000/ $3,250/ $1,000/ $3,000/
(Individual/Family) $2,000 $9,750 $2,000 N/A $6,000 N/A
Out-of-Pocket Maximum per $4,000/ $6,000/ $4,000/ $4,000/
Calendar Year $8,000 $18,000 $8,000 N/A $8,000 N/A
(Individual/Family)
$250 copay then $250 copay then
Emergency Care 0% after deductible
In-Network Coinsurance In-Network Coinsurance
Hospital Care 20% 50% 20% after ded N/A 0% after ded. N/A
Office Visits
Primary Care & Designated
Network Specialist $25 50% after ded. $25 N/A 0% after ded. N/A
Under 19/Dependent Office Visit $0 Copay N/A $0 Copay N/A N/A N/A
Specialist $50 50% after ded. $50 N/A 0% after ded. N/A
Virtual Visit $0 Copay N/A $0 Copay N/A $50 Copay N/A
Urgent Care $75 50% after ded. $75 N/A 0% after ded. N/A
Amount you pay after
Prescription Drug Program (30 day supply)
deductible
30% of cost
Tire 1 – Preferred Generic $10 $10 N/A $10 N/A
after copay
Tier 2 – Preferred Name 30% of cost
Brand Drugs $35 after copay $35 N/A $35 N/A
30% of cost
Tier 3 – Brand Name Drugs $85 $85 N/A $70 N/A
after copay
Tier 1: $10, Tier 1: $10, Tier 1: $10,
Specialty Drugs Tier 2: $150, 30% of cost Tier 2: $150, N/A Tier 2: $150, N/A
(Preferred & Non-Preferred) after copay
Tier 3: $500 Tier 3: $500 Tier 3: $500
To find more information on In-Network Providers, Prescription Drug Lists, Explanations of Benefits, and various other information log-in
to www.myuhc.com.
90 Day Mail order is available at 2.5 times your 30 Day Retail copay amount. See SBC for pricing.

7 7