Page 5 - Summit LTC Management LLC - Benefit Guide GROUP 1 Effective Dec 1, 2019 Revised July 2020
P. 5
Medical Options:
United Healthcare (UHC)
2020 Effective 12-1-19
Semi-Monthly Per Pay Period We offer our full-time employees and
their eligible dependents coverage.
Employee Only $140.00 Children can join or remain on a
Employee + Spouse $531.00 parent’s medical plan until age 26.
Employee + Child(ren) $401.00 When a child turns 26, they will lose
medical coverage on the last day of
Employee + Family $792.00
PROformance BM-DO
Brief Member In-Network Summary $6,000 Deductible
IN-NETWORK ONLY Coverage
Network CHOICE
Individual: $6,000
(CYD) Calendar Year Deductible (Jan .1st to Dec. 31st)
Family: $12,000
Health Reimbursement Arrangement (HRA) After $3,000 CYD is
Individual/Family reimburse up to next $3,000
met of your in-network deductible (CYD)
Coinsurance (After CYD) Carrier: 80% Member: 20%
Individual: $6,350
Annual (OOP) Out of Pocket Maximum
Family: $12,700
Primary Care Physician (PCP) Under Age 19: $0 Copay / Over Age 19: $10 Copay
UHC Network Providers
Specialist Physicians and Providers $40 Copay -Designated
$80 Copay -Standard
Dr. Consultation Virtual Visits, See Pg. 7 $0 Copay
COVID Testing and Treatment (during COVID period) Covered 100% (No CYD, Co-Ins. Copays)
Basic: $40 Copay
Basic: Lab, X-Rays & Diagnostic/Major: Diagnostic & Imaging
Major: $500 Copay
Annual Preventive Care Certain Rx are covered too, See Page 4 Covered 100% (No CYD, Co-Ins. Copays)
Urgent Care $25 copay (Dr. Services Only) (CYD/20% apply to other services)
Emergency Room 20% after $300 Copay after Calendar Year Deductible (CYD)
Hospitalization: In / Outpatient 20% after Calendar Year Deductible (CYD)
RX Plan IU
Prescription Drugs - 31 Day Supply Retail Tier 1 $15 Copay
90 Day Supply Mail Order at 2.5 Times Retail Tier 2 $40 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 5
