Page 4 - Frank Bailey Grain 2021-2021 Benefit Guide

Medical Option:

United Healthcare

Rates Per Pay Period
Dependent Information
Coverage Tier Weekly Monthly
Frank Bailey Grain, Co. offers employees the
Employee Only $ 36.46 $158.00 opportunity to cover their dependent children.
Children can join or remain on a parent’s
Employee + Spouse $ 143.31 $621.00
medical plan until age 26. When a child turns 26,
Employee + Child(ren) $ 88.85 $385.00 they will lose medical coverage on the last day
of their birth month.
Employee + Family $192.00 $832.00

Your Cost In Network Benefits Out of Network Benefits

Member Calendar Year Individual: $2,500 Individual: $5,000
Deductible (CYD) Family: $7,500 Family: $15,000
Carrier 100% / Member 0% Carrier 70% / Member 30%
Coinsurance
After Calendar Year Deductible After Calendar Year Deductible
Member Responsibility:
Health Reimbursement First $1,250 of deductible Limited to In-Network Amount
Arrangement (HRA) Frank Bailey Grain Responsibility:
Second $1,250 of deductible

Out of Pocket Maximum Plan pays 100% after members Calendar Individual: $10,000 after CYD
(Does not include Rx and Year Deductible CYD). Family: $30,000 after CYD
Copays)
Office Visit - Primary $25 Copay 30% After Deductible
Care Physician/ PCP
Designated Network : $25 Copay
Office Visit - Specialist 30% After Deductible
Network: $50 Copay
Preventive Care Covered 100% (No Deductible or Copay) 30% After Deductible

Urgent Care $75 Copay 30% After Deductible
Lab / X– Ray Paid 100% 30% After Deductible

Emergency Room $200 Copay $200 Copay

Hospitalization: 0% after CYD Inpatient: 0% after CYD plus $500 Copay
In / Out Patient Outpatient: 0% after CYD plus $250 Copay

Prescription Drugs Retail
31 Day Supply Tier 1 $15 Copay Tier 1 $15 Copay
Tier 2 $40 Copay Tier 2 $40 Copay
90 Day Supply Mail Order Tier 3 $70 Copay Tier 3 $70 Copay
at 3 Times Retail Copay.
Specialty Tier 1 $15 Copay Specialty Tier 1 $15 Copay
(Rx has $3,000 Annual Specialty Tier 2 20% Specialty Tier 2 25%
Individual $9,000 Family Specialty Tier 3 25% Specialty Tier 3 25%
Maximum)

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