Page 4 - Megatel Homes LLC 2019 Benefit Guide-Revised 042220

Medical Options:

United Healthcare (UHC)

H.S.A Plan Navigate Premier Premier
2019 Effective 8-1-19 AGX9-MM HMO Value BC1H-IU
Bi-Weekly Per Pay Period We offer our full-time employees and
AYZB-IU BC2A-IU their eligible dependents coverage.
Employee Only $ 44.28 $ 69.35 $ 88.38 $123.66 Children can join or remain on a
parent’s medical plan until age 26.
Employee + Spouse $358.08 $421.36 $469.42 $558.48
When a child turns 26, they will lose
Employee + Child(ren) $252.31 $302.72 $341.00 $411.93 medical coverage on the last day of
their birth month.
Employee + Family $552.81 $639.81 $705.89 $828.32

Brief Member H.S.A Plan AGX9 Navigate HMO AYZB Premier Value BC2A emier BC1H
r
P
In-Network $6,350 Deductible $5,000 Deductible $5,000 Deductible $2,500 Deductible
Summary IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY
Network CHOICE Navigate “TEXAS—Only” CHOICE CHOICE
(CYD) Calendar Year
Individual: $6,350 Individual: $5,000 Individual: $5,000 Individual: $2,500
Deductible (Jan .1st to
Family: $12,700 Family: $10,000 Family: $10,000 Family: $5,000
Dec. 31st)
Coinsurance Carrier: 100% Carrier: 100% Carrier: 80% Carrier: 70%
(After CYD) Member: 0% Member: 0% Member: 20% Member: 30%
Annual (OOP) Out of Individual: $6,350 Individual: $7,350 Individual: $6,350 Individual: $6,000
Pocket Maximum Family: 12,700 Family: 14,700 Family: $12,700 Family: $12,000
(PCP) Primary Care Under Age 19: $0 Copay Under Age 19: $0 Copay Under Age 19: $0 Copay
0% after CYD
Physician Over Age 19: $10 Copay Over Age 19: $45 Copay Over Age 19: $30 Copay
$60 Copay (you must have a
Specialist Physicians referral from your PCP) Not UHC Network Providers UHC Network Providers
0% after CYD needed for (OB/GYN’s)., Urgent Care, $45 Copay -Designated $30 Copay -Designated
and Providers
Behavioral health or use $90 Copay -Standard $60 Copay -Standard
disorder clinicians.
Dr. Consultation Member Pays $49 Cost
$0 Copay $0 Copay $0 Copay
Virtual Visits Per Consultation
Basic: Lab, X-Rays &
Basic: $40 Copay CYD Waived Basic: 20% after CYD Basic: Paid 100%
Diagnostic/Major: 0% after CYD
Major: $500 Copay Major: $400 Copay Major: 30% after CYD
Diagnostic & Imaging
Annual Preventive
Covered 100% Covered 100% Covered 100% Covered 100%
Care (Certain Rx are
(No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
covered too)
$100 co
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$25 copay (Dr. Services Only) y)
Urgent Care 0% after CYD $75 Copay
(CYD apply to other services) (CYD/20% apply to other services)
20% after $400 Copay 30% after $250 Copay
Emergency Room 0% after CYD $500 Copay, after CYD
CYD does not apply CYD does not apply
Hospitalization: 0% after CYD 20% after CYD /
0% after CYD 30% after CYD
In / Outpatient (you must have a referral from your PCP) $250 Copay Applies
Prescription Drugs - RX Plan MM RX Plan IU RX Plan IU RX Plan IU
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31 Day Supply Retail Tier 1 $15 Copay r 1 $15 Copay r 1 $15 Copay
T
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90 Day Supply Mail 0% after CYD Tier 2 $40 Copay r 2 $40 Copay r 2 $40 Copay
Order at 2.5 Times Tier 3 $75 Copay Tier 3 $75 Copay Tier 3 $75 Copay
Retail
NOTE: This is only a brief overview. Please see Benefit Summary and SBC for more details. Please Register and use UHC Member www.myuhc.com or
4 Customer Service Toll Free 866-633-2446, for Navigate 855-828-7715 , for H.S.A 866-314-0335