Page 4 - Pampa Benefit Guide 4-1-24

Medical Options:

United Healthcare (UHC)

24 Pay Periods Platinum PPO Gold EPO Silver HMO We offer our full-time employees and their
CVAS/K35Y E2500i70 Nave3500i70
eligible dependents coverage. Children
Employee Only $205.00 $155.00 $115.00 can join or remain on a parent’s medical
Employee + Spouse $580.00 $430.00 $380.00 plan until age 26. When a child turns 26,
they will lose medical coverage on the last
Employee + Child(ren) $570.00 $420.00 $370.00
day of their birth month.
Employee + Family $925.00 $725.00 $625.00

EPO—E1500i80LX21B EPO— E2500i70LX21B HMO—Nave3500i70LX21B
Brief Member $1,500 Deductible $2,500 Deductible $3,500 Deductible
In-Network Summary
IN NETWORK ONLY IN NETWORK ONLY IN NETWORK ONLY
Network UHC Choice—Nationwide UHC Choice—Nationwide UHC Navigate—TX Statewide
(CYD) Calendar Year Deductible Individual: $1,500 Individual: $2,500 Individual: $3,500
(Jan .1st to Dec. 31st) Family: $3,000 Family: $7.500 Family: $7,000
Coinsurance:
Carrier: 80% Carrier: 70% Carrier: 70%
After Calendar Year Deductible
Member: 20% Member: 30% Member: 30%
CYD)
Annual (OOP) Out of Pocket Individual: $5,000 Individual: $8,000 Individual: $8,150
Maximum Family: $10,000 Family: 16,000 Family: $16,300
Under Age 19: $0 Copay Under Age 19: $0 Copay Under Age 19: $0 Copay
Primary Care Physician (PCP)
Over Age 19: $25 Copay Over Age 19: $25 Copay Over Age 19: $25 Copay
Specialist Physicians and Non $75 Copay
$75 Copay $75 Copay
PCP Providers Electronic Referral Required by PCP
Dr. Consultation Virtual Visits
$0 Copay $0 Copay $0 Copay
(Telehealth)
Basic: Lab, X-Rays & Diagnostic/
20% after CYD 30% after CYD 30% after CYD
Major: Diagnostic & Imaging
Annual Preventive Care (Certain Covered 100% Covered 100% Covered 100%
Rx are covered too) Page 5 (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
$50 Copay $50 copay $50 copay
Urgent Care
(others charges may apply) (others charges may apply) (others charges may apply)
Emergency Room $300 Copay, after CYD and 20% $300 Copay, after CYD and 30% $300 Copay, after CYD and 30%
Hospitalization:
20% after CYD 30% after CYD 30% after CYD
(In / Outpatient)
Tier 1 $10 Copay Tier 1 $10 Copay Tier 1 $10 Copay
Retail Drug Plan Tier 2 $35 Copay Tier 2 $35 Copay Tier 2 $35 Copay
Prescription Drugs - 31 Day Tier 3 $75 Copay Tier 3 $75 Copay Tier 3 $75 Copay
Supply Retail Tier 4 $250 Copay Tier 4 $250 Copay Tier 4 $250 Copay
90 Day Supply Mail Order at 2.5 Specialty Drugs Specialty Drugs Specialty Drugs
Times Retail Tier 1 $10, Tier 2 $150 Copay Tier 1 $10, Tier 2 $150 Copay Tier 1 $10, Tier 2 $150 Copay
Tier 3 $350, Tier 4 $500 Copay Tier 3 $350, Tier 4 $500 Copay Tier 3 $350, Tier 4 $500 Copay

CVS Pharmacy is NO longer in-network
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 4