Page 4 - Megatel Homes LLC Benefit Guide FINAL DRAFT 8-1-2025

Medical Options:

United Healthcare

Effective 8-1-25 H.S.A Plan HMO Value Premier
Bi-Weekly (26) Per Pay Period Plan A Plan B Plan
We offer our full-time employees and
Employee Only $ 68.23 $ 98.21 $116.05 $146.16 their eligible dependents coverage.
Children can join or remain on a
Employee + Spouse $275.32 $371.72 $409.26 $468.63
parent’s medical plan until age 26.
Employee + Child(ren) $238.55 $295.50 $325.50 $373.16 When a child turns 26, they will lose
medical coverage on the last day of
Employee + Family $390.64 $463.19 $538.26 $626.32 their birth month.

H.S.A Plan Navigate HMO
Brief Member NavE5000i10021B Choice E5000i8021B Premier DQ5K
Choice HE635025B
In-Network $6,350 Deductible $5,000 Deductible $5,000 Deductible $3,000 Deductible
Summary IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY
PREMIER option with NO Specialist
LOW COST HMO option with FIRST Dollar
Difference Between HSA-Compatible High Deductible coverage with Copays (CYD Waived) on MID-RANGE option with NO Specialist Referral Required. FISRT Dollar
Health Plans (HDHP) Lower coverage with Copays (CYD Waived)
Plans Annual Out of Pocket MOST Day to Day Services. Referral Referral Required. on MOST Day to Day Services Lower
Required for Specialist
Calendar Yr Deductible
Network CHOICE Navigate “TEXAS—Only” CHOICE CHOICE
(CYD) Calendar Year Individual: $6,350 Individual: $5,000 Individual: $5,000 Individual: $3,000
Family: $12,700 Family: $10,000 Family: $10,000 Family: $6,000
Deductible (Jan .1st to Dec. 31st)
Coinsurance Carrier: 100% Carrier: 100% Carrier: 80% Carrier: 80%
(After CYD) Member: 0% Member: 0% Member: 20% Member: 20%
Annual (OOP) Out of Individual: $6,350 Individual: $8,150 Individual: $8,150 Individual: $8,150
Pocket Maximum Family: 12,700 Family: $16,300 Family: $16,300 Family: $16,300
(PCP) Primary Care 0% after CYD Under Age 19: $0 Copay Under Age 19: $0 Copay Under Age 19: $0 Copay
Physician Over Age 19: $25 Copay Over Age 19: $25 Copay Over Age 19: $25 Copay
Specialist Physicians 0% after CYD $75 Copay $75 Copay $75 Copay
and Providers
YES, Not needed for (OB/GYN’s).,
Referral Required for Urgent Care, Behavioral health or
Specialists NO use disorder clinicians. NO NO
Dr. Consultation Virtual Member Pays $54
$0 Copay $0 Copay $0 Copay
Visits, See Pg. 8 Cost Per Consultation
Basic: Lab, X-Rays &
0% after CYD Paid 100% No Charge Paid 100% No Charge Paid 100% No Charge
Diagnostic Tests
Major: Diagnostic & Calendar Year Deductible 20% after Calendar Year 20% after Calendar Year
Imaging 0% after CYD Applies Deductible (CYD) Deductible (CYD
Annual Preventive Care Covered 100% Covered 100% Covered 100% Covered 100%
Certain Rx are covered too,
See Page 5 (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
Urgent Care 0% after CYD $50 copay $50 copay $50 copay

Emergency Room 0% after CYD $300 Copay, after CYD $300 Copay, 20% after CYD $300 Copay, 20% after CYD
Hospitalization: 0% after CYD 20% after CYD /
0% after CYD 20% after CYD
In / Outpatient (you must have a referral from your PCP) $250 Copay Applies
Prescription Drugs - 31
T
e
i
Tier 1 $10 Copay r 1 $15 Copay r 1 $15 Copay
e
T
i
Day Supply Retail
T
e
i
0% after CYD Tier 2 $35Copay r 2 $40 Copay r 2 $40 Copay
e
i
T
90 Day Supply Mail
Tier 3 $75 Copay Tier 3 $75 Copay Tier 3 $75 Copay
Order at 2.5 Times
Tier 4 $250 Copay
Retail
Specialty Drugs Own Copays
4 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 , for H.S.A 866-314-0335