Page 5 - Heritage Oaks_Benefit Guide 7-1-2022

Medical Options:

United Healthcare (UHC)

Charter/HMO Navigate/HMO Charter/HMO
Effective 7-1-2022 We offer our full-time employees and
Bi-Weekly Pay Period AYZG-997Y AYZL-997Y BCXV-997Y
their eligible dependents coverage.
Employee Only $ 79.19 $111.62 $134.76 Children can join or remain on a
Employee + Spouse $368.07 $435.78 $483.63 parent’s medical plan until age 26.
When a child turns 26, they will lose
Employee + Child(ren) $314.94 $375.81 $419.57
medical coverage on the last day of
Employee + Family $596.14 $695.61 $766.15 their birth month.

Charter HMO AYZG Navigate HMO AYZL Charter HMO BCXV
Brief Member
$5,000 Deductible $5,000 Deductible $3,000 Deductible
Benefit Summary IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY

Network Charter (DFW) Navigate (Texas) Charter (DFW)

(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: 100% Carrier: 80% Carrier: 100%
(After CYD) Member: 0% Member: 20% Member: 0%

Annual (OOP) Out of Pocket Individual: $7,350 Individual: $7,350 Individual: $5,500
Maximum Family: $14,700 Family: $14,700 Family: $11,000
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: $15 Copay
$60 Copay (you must have a $60 Copay (you must have a $45 Copay (you must have a
Specialist Physicians and Non referral from your PCP) Not needed for referral from your PCP) Not needed referral from your PCP) Not needed for
PCP Providers (OB/GYN’s)., Urgent Care, Behavioral health or for (OB/GYN’s)., Urgent Care, Behavioral (OB/GYN’s)., Urgent Care, Behavioral health or
use disorder clinicians. health or use disorder clinicians. use disorder clinicians.

Dr. Consultation Virtual Visits
$0 Copay $0 Copay $0 Copay
(Telehealth)
Basic: Lab, X-Rays & Diagnostic/ Basic: $40 Copay Basic: $40 Copay Basic: Covered 100%
Major: Diagnostic & Imaging Major: $500 Copay Major: $500 Copay Major: $500 Copay
(CT, CT, MRI, etc.) CYD Waived CYD Waived CYD Waived
Annual Preventive Care (Certain Covered 100% Covered 100% Covered 100%
Rx are covered too) (See Page 4) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
Urgent Care $25 copay, CYD Waived $25 copay, CYD Waived $75 copay, CYD Waived

Emergency Room $500 Copay, after CYD and 20% $500 Copay, after CYD and 20% $500 Copay, CYD Waived

Hospitalization: Carrier pays 100% after CYD Carrier 80% Member 20% after CYD Carrier pays 100% after CYD
(In / Outpatient) (you must have a referral from your PCP) (you must have a referral from your PCP) (you must have a referral from your PCP)
RX Plan 997Y RX Plan 997Y RX Plan 997Y
Prescription Drugs - 31 Day Supply Tier 1 $10 Copay Tier 1 $10 Copay Tier 1 $10 Copay
Retail
Tier 2 $50 Copay Tier 2 $50 Copay Tier 2 $50 Copay
90 Day Supply Mail Order at 2.5 Times Tier 3 $100 Copay Tier 3 $100 Copay Tier 3 $100 Copay
Retail Specialty Tier 1 $10 Copay Specialty Tier 1 $10 Copay Specialty Tier 1 $10 Copay
Specialty Tier 2 $150 Copay Specialty Tier 2 $150 Copay Specialty Tier 2 $150 Copay
CVS No Longer In-Network Specialty Tier 3 $500 Copay Specialty Tier 3 $500 Copay Specialty Tier 3 $500 Copay
CVS Not In Network CVS Not In Network CVS Not In Network

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