Page 4 - 2022 ANS Benefit Guide

Medical Option:

United Healthcare

Rates Per Pay Period
Dependent Information
Coverage Tier 24 26
Our company offers employees the opportunity
Employee Only $ 80.89 $ 74.66 to cover their dependent children. Children can

Employee + Spouse $261.53 $241.41 join or remain on a parent’s medical plan until
age 26. When a child turns 26, they will lose
Employee + Child(ren) $288.49 $266.30
medical coverage on the last day of their birth
Employee + Family $412.51 $380.78 month.

Your Cost In Network Benefits Out of Network Benefits

Member Calendar Year Individual: $2,000 Individual: $5,000
Deductible (CYD) Family: $4,000 Family: $10,000
Jan.1 through Dec. 31st.

Carrier 80% / Member 20% Carrier 50% / Member 50%
Coinsurance
After Calendar Year Deductible After Calendar Year Deductible
Out of Pocket Maximum Individual: $7,350 Individual: $10,000
Jan. 1, through Dec. 31st. Family: $14,700 Family: $20,000

Office Visit - Primary $25 Copay 50% After Calendar Year Deductible
Care Physician/ PCP

Designated Network : $25 Copay
Office Visit - Specialist 50% After Calendar Year Deductible
Network: $50 Copay
Covered 100%
Preventive Care 50% After Calendar Year Deductible
(No Deductible, Coins, Copay’s)

Urgent Care $50 Copay 50% After Calendar Year Deductible
Diagnostic Test (X–Ray / $40 Copay 50% After Calendar Year Deductible
Blood Work)
Imaging (CT, PET scans, 50% After Calendar Year Deductible
MRI’s $500 Copay

Emergency Room $250 Copay / 20% Coins Applies $250 Copay / 20% Coins Applies

Hospitalization: 20% after CYD 50% After Calendar Year Deductible
In / Out Patient

Prescription Drugs Retail Regular / Specialty Regular / Specialty
31 Day Supply Tier 1 $10 Copay / $10 Copay Tier 1 $10 Copay / $10 Copay
Tier 2 $40 Copay / $40 Copay Tier 2 $40 Copay / $40 Copay
90 Day Supply Mail Order Tier 3 $105 Copay / $105 Copay Tier 3 $105 Copay / $105 Copay
at 2.5 Times Retail.
Tier 4 $250 Copay / $500 Copay Tier 4 $250 Copay / $500 Copay
Other Limits Apply

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