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Medical Options:

United Healthcare (UHC)

For your Pre-Taxed costs per pay period We offer our full-time employees and their eligible
dependents coverage. Children can join or remain on
please see rates when you enroll online. a parent’s medical plan until age 26. When a child
turns 26, they will lose medical coverage on the last
day of their birth month.

G
Summary of Plan OOD PLAN BETTER PLAN BEST PLAN
In-Network Benefits and Charter HMO BRQA $5,500 Navigate HMO BRRW Premier BRRB
Member Costs Deductible $4,000 Deductible $1,500 Deductible
Charter HMO Network Navigate HMO Network Choice Network
UHC Network
DFW—Only Texas Only National
(CYD) Calendar Year Deductible Individual: $5,500 Individual: $4,000 Individual: $1,500
January 1st to December 31st Family: $11,000 Family: $8,000 Family: $4,500

Coinsurance Carrier: 80% / Member: 20% Carrier: 80% / Member: 20% Carrier: 100% / Member: 0%
Calendar Year Annual Out of
Individual: $7,900 Individual: $6,900 Individual: $6,000
Pocket Maximum (Copays, CYD
Family: $15,800 Family: $13,800 Family: $12,000
Deductibles and Coinsurance)
$0 Copay -Under Age 19: $0 Copay -Under Age 19: $0 Copay -Under Age 19:
(PCP) Primary Care Physician
$35 Copay -Age 19 or Older $10 Copay -Age 19 or Older $20 Copay -Age 19 or Older
$40/$80 Copay (must have a
$105 Copay (must have a referral referral from your PCP) Not needed Network Providers
from your PCP) Not needed for (OB/
Specialist Physicians & Providers for (OB/GYN’s)., Urgent Care, Behavioral $20 Copay -Designated
GYN’s)., Urgent Care, Behavioral health or
use disorder clinicians. health or use disorder $40 Copay -Standard
clinicians.
Dr. Consultation Virtual Visits $0 Copay $0 Copay $0 Copay
Basic: Lab, X-Rays & Diagnostic / Basic: 20% after CYD Basic: $40 Copay, No CYD Basic: Paid 100%
Major: Diagnostic & Imaging Major: $500 Copay No CYD Major: $500 Copay No CYD Major: $400 Copay, No CYD
Co
Co
Preventive Care (Certain Rx are Covered 100% vered 100% vered 100%
covered too) (No CYD, Co-Ins. Copay) (No CYD, Co-Ins. Copay) (No CYD, Co-Ins. Copay)
$50 copay (Dr. Services) rvices)
ay (
p
. S
e
Dr
$25 c
o
Urgent Care $50 Copay
(CYD apply to other services) (CYD apply to other services)
Emergency Room $650 Copay, No CYD $300 Copay plus 20% after CYD $350 Copay, No CYD
$400 Copay plus 20% after CYD
Hospitalization: 20% after CYD (must have referral
(must have referral from your PCP 0% after CYD
In / Out Patient from your PCP for Specialist)
for Specialist)
Exams, Lenses, Frames paid after Exams, Lenses, Frames paid after Exams, Lenses, Frames paid after
Vision—Pediatric Only to Age 19
Copays up to plan limits Copays up to plan limits Copays up to plan limits
Tier 1 $5 Copay
Tier 1 $20 Copay Tier 1 $10 Copay
Prescription Drugs : Tier 2 $50 Copay
Tier 2 $45 Copay Tier 2 $35 Copay
31 Day Supply Retail Tier 3 $100 Copay
Tier 3 $80 Copay Tier 3 $60 Copay
90 Day Supply Mail Order at 2.5 Tier 4 $250 Copay
Specialty Drugs Specialty Drugs
Specialty Drugs Specialty Drugs
$20/$100/$300 $10/$100/$300
Same Tiers
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 UHC EPO 866-633-2446, Charter and Navigate Plans 855-828-7715
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