Page 4 - Revelations - GROUP 1 2021 Arl. Res. Benefit Guide (R3)

Medical Options:

United Healthcare (UHC)

Charter/HMO Navigate/HMO Premier /EPO
Effective 1-1-2020 We offer our full-time employees and
Bi-Weekly Pay Period AYZQ-IU AYZL-IU BCZ2-IU
their eligible dependents coverage.
Employee Only $106.13 $128.05 $ 196.50 Children can join or remain on a
Employee + Spouse $455.03 $503.25 $ 653.84 parent’s medical plan until age 26.
When a child turns 26, they will lose
Employee + Child(ren) $353.27 $393.82 $ 520.45
medical coverage on the last day of
Employee + Family $745.78 $815.92 $1,034.96 their birth month.

Charter HMO AYZL $5,000 Navigate HMO AYZL Premier BCZ2
Brief Member 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
(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-
health or
use disorder clinicians. $60 Copay -Standard
cians.
COVID Testing and Treatment Covered 100% Covered 100% Covered 100%
(during COVID period) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
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)
Prescription Drugs - 31 Day RX Plan IU RX Plan IU RX Plan IU
Supply Retail Tier 1 $15 Copay Tier 1 $15 Copay Tier 1 $15 Copay
90 Day Supply Mail Order at Tier 2 $40 Copay Tier 2 $40 Copay Tier 2 $40 Copay
2.5 Times Retail Tier 3 $75 Copay Tier 3 $75 Copay Tier 3 $75 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

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