Page 5 - Heritage Oaks - Benefit Guide 7-1-2020 Revised 091120

Medical Options:

United Healthcare (UHC)

Effective 1-1-2020 We offer our full-time employees and
Charter/HMO Navigate/HMO Charter/HMO
Bi-Weekly Pay Period BCXW-IU AYZL-IU BCXT-IU
their eligible dependents coverage.
Employee Only $ 70.01 $ 75.14 $109.55 Children can join or remain on a
Employee + Spouse $336.26 $338.03 $400.79 parent’s medical plan until age 26.
When a child turns 26, they will lose
Employee + Child(ren) $290.61 $290.77 $346.88
medical coverage on the last day of
Employee + Family $528.48 $572.26 $668.15 their birth month.

Charter HMO BCXW Navigate HMO AYZL Charter HMO BCXT
Brief Member
$5,000 Deductible $5,000 Deductible $2,000 Deductible
Benefit Summary IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY

Network Charter “Current” Navigate “Larger PCP Network” Charter “Current”

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

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

Annual (OOP) Out of Pocket Individual: $6,500 Individual: $7,350 Individual: $4,500
Maximum Family: $13,000 Family: $14,700 Family: $9,000
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: $10 Copay Over Age 19: $15 Copay
$75 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: Covered 100% 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)
$25 copay (Dr. Services Only)
Urgent Care $100 copay $75 copay
(CYD/20% apply to other services)
Emergency Room $500 Copay, after CYD $500 Copay, after CYD and 20% $500 Copay, after CYD

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 IU RX Plan IU RX Plan IU
Prescription Drugs - 31 Day
Supply Retail Tier 1 $15 Copay Tier 1 $15 Copay Tier 1 $15 Copay
Tier 2 $40 Copay Tier 2 $40 Copay Tier 2 $40 Copay
90 Day Supply Mail Order at
Tier 3 $75 Copay Tier 3 $75 Copay Tier 3 $75 Copay
2.5 Times Retail
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
5