Page 4 - GROUP 1 2022 Arlington Res. Benefit Guide Revised

Medical Options:

United Healthcare (UHC)

Charter/HMO Navigate/HMO Premier /EPO
Effective 1-1-2022 We offer our full-time employees and
Bi-Weekly Pay Period AYZQ-G58Y AYZL-G58Y BCZ2-G58Y
their eligible dependents coverage.
Employee Only $145.44 $170.32 $ 268.98 Children can join or remain on a
Employee + Spouse $541.51 $596.25 $ 813.31 parent’s medical plan until age 26.
When a child turns 26, they will lose
Employee + Child(ren) $425.99 $472.02 $ 654.55
medical coverage on the last day of
Employee + Family $871.57 $951.19 $1,266.91 their birth month.

Charter HMO AYZQ Navigate HMO AYZL Premier BCZ2
Brief Member $5,000 Deductible $5,000 Deductible $3,000 Deductible
In-Network Summary IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY

Network Charter “DFW—Only” Navigate “TEXAS—Only” CHOICE—Nationwide
(CYD) Calendar Year Deductible Individual: $5,000 Individual: $5,000 Individual: $3,000
(Jan .1st to Dec. 31st) Family: $10,000 Family: $10,000 Family: $6,000
Coinsurance Carrier: 80% Carrier: 80% Carrier: 80%
After Calendar Year Deductible Member: 20% Member: 20% Member: 20%
CYD)
Annual (OOP) Out of Pocket Individual: $7,350 Individual: $7,350 Individual: $6,000
Maximum Family: 14,700 Family: 14,700 Family: $12,000
Under Age 19: $0 Copay Under Age 19: $0 Copay Under Age 19: $0 Copay
Primary Care Physician (PCP)
Over Age 19: $10 Copay Over Age 19: $10 Copay Over Age 19: $30 Copay
$60 Copay (you must have a
$60 Copay (you must have a UHC Network Providers
Specialist Physicians and Non referral from your PCP) Not needed for referral from your PCP) Not needed $30 Copay -Designated
PCP Providers (OB/GYN’s)., Urgent Care, Behavioral health or for (OB/GYN’s)., Urgent Care, Behavioral
use disorder clini-
use disorder clinicians. health or cians. $60 Copay -Standard
Dr. Consultation Virtual Visits $0 Copay $0 Copay $0 Copay
(Telehealth)
Basic: Lab, X-Rays & Diagnostic/ Basic: $40 Copay CYD Waived Basic: $40 Copay CYD Waived Basic: Paid 100%
Major: Diagnostic & Imaging Major: $500 Copay Major: $500 Copay Major: 20% after CYD
Annual Preventive Care Covered 100% Covered 100% Covered 100%
(Certain Rx are covered too) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
$25 copay $25 copay
Urgent Care $75 Copay
(others charges may apply) (others charges may apply)
20% after $250 Copay
Emergency Room $500 Copay, after CYD and 20% $500 Copay, after CYD and 20%
CYD does not apply
Hospitalization:
20% after CYD 20% after CYD 20% after CYD
(In / Outpatient)
RX Plan G58Y RX Plan G58Y RX Plan G58Y
Prescription Drugs - 31 Day Tier 1 $10 Copay Tier 1 $10 Copay Tier 1 $10 Copay
Supply Retail Tier 2 $45 Copay Tier 2 $45 Copay Tier 2 $45 Copay
90 Day Supply Mail Order at Tier 3 $80 Copay Tier 3 $80 Copay Tier 3 $80 Copay
2.5 Times Retail Specialty Tier 1 $10 Copay Specialty Tier 1 $10 Copay Specialty Tier 1 $10 Copay
PRESCRIPTION DRUG LIST is Specialty Tier 2 $150 Copay Specialty Tier 2 $150 Copay Specialty Tier 2 $150 Copay
ADVANTAGE Specialty Tier 3 $500 Copay Specialty Tier 3 $500 Copay Specialty Tier 3 $500 Copay

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
Customer Service Toll Free 866-633-2446, for Navigate 855-828-7715

4