Page 5 - 2022 Extended Care and Rehabilitation of Arlington Benefit Guide

Medical Options:

United Healthcare (UHC)

Effective 5/1/2022 r HMO Navigate HMO Premier Premier We offer our full-time employees and their eligible
Charte
26 Pay Periods BEIJ-G58Y BEII-G58Y BCZS-G58Y BCZQ-G58Y
dependents coverage. Children can join or remain
Employee Only $ 27.89 $ 37.08 $ 99.17 $112.70 on a parent’s medical plan until age 26. When a
Employee + Spouse $215.46 $255.14 $388.43 $421.16 child turns 26, they will lose medical coverage on the
Employee + Child(ren) $144.26 $189.42 $188.11 $297.77 last day of their birth month.
Employee + Family $390.74 $444.72 $628.12 $673.17

Brief Member Charter HMO BEIJ Navigate HMO BEII Premier BCZS Premier BCZQ
Network Summary $6,000 Deductible $6,000 Deductible $3,000 Deductible $2,000 Deductible
IN-NETWORK COVERAGE Limited PCP Network Large Network Large Network Large Network
ONLY (Houston and DFW) (Texas Only) (Nationwide) (Nationwide)

Network Name and Areas CHARTER “Houston & DFW” Area” NAVIGATE “TEXAS” Only CHOICE “Nationwide” CHOICE “Nationwide”
(CYD) Calendar Year Deductible Individual: $6,000 Individual: $6,000 Individual: $3,000 Individual: $2,000
(Jan .1st to Dec. 31st) Family: $12,000 Family: $12,000 Family: $6,000 Family: $4,000
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Coinsurance Carrier: 100% rrier: 100% ier: 100% arrier: 100%
(After Calendar Year Deductible) Member: 0% Member: 0% Member: 0% Member: 0%
Annual (OOP) Out of Pocket Individual: $7,350 Individual: $7,350 Individual: $4,500 Individual: $3,500
Maximum—Includes all CYD, Family: $14,700 Family: $14,700 Family: $9,000 Family: $7,000
Copays and Coinsurance
Under Age 19: $0 Copay Under Age 19: $0 Copay Under Age 19: $0 Copay ge 19: $0 Copay
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Primary Care Physician (PCP)
Age 19 & Over: $10 Copay Age 19 & Over: $10 Copay Age 19 & Over: $30 Copay Age 19 & Over: $30 Copay
$60 Copay (you must have a $60 Copay (you must have a UHC Network Providers UHC Network Providers
Specialist Physicians and Non referral from your PCP) Not needed for referral from your PCP) Not needed $30 Copay -Designated $30 Copay -Designated
PCP Providers (OB/GYN’s)., Urgent Care, Behavioral health or for (OB/GYN’s)., Urgent Care, Behavioral health or
use disorder clinicians. use disorder clinicians. $60 Copay -Standard $60 Copay -Standard
Dr. Consultation Virtual Visits
(Telehealth) see page 6 & 7 $0 Copay $0 Copay $0 Copay $0 Copay
Basic: Lab, X-Rays / Diagnostic Basic: $40 Copay CYD Waived Basic: $40 Copay CYD Waived Basic: Paid 100% Basic: Paid 100%
Major: Diagnostic & Imaging Major: $500 Copay Major: $500 Copay Major: Paid 100% after CYD Major: Paid 100% after CYD
Annual Preventive Care (Certain Covered 100% Covered 100% overed 100% ered 100%
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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)
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$25 Copay (Dr. Services Only) nly)
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Urgent Care $75 Copay $75 Copay
(CYD apply to other services) (CYD apply to other services)
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$300 Copay 00 Copay
Emergency Room $500 Copay, after CYD $500 Copay, after CYD
CYD does not apply CYD does not apply
Hospitalization: Paid 100% after CYD Paid 100% after CYD Paid 100% after CYD Paid 100% after CYD
(In / Outpatient)
RX Plan G58Y RX Plan G58Y RX Plan G58Y RX Plan G58Y
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Tier 1 $10 Copay Tier 1 $10 Copay r 1 $10 Copay 1 $10 Copay
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Prescription Drugs - 31 Day Tier 2 $45 Copay ier 2 $45 Copay r 2 $45 Copay $45 Copay
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Supply Retail Tier 3 $80 Copay Tier 3 $80 Copay Tier 3 $80 Copay Tier 3 $80 Copay
90 Day Supply Mail Order at 2.5 Specialty Tier 1 $10 Copay Specialty Tier 1 $10 Copay Specialty Tier 1 $10 Copay Specialty Tier 1 $10 Copay
Times Retail
Specialty Tier 2 $150 Copay Specialty Tier 2 $150 Copay Specialty Tier 2 $150 Copay pecialty Tier 2 $150 Copay
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Specialty Tier 3 $500 Copay Specialty Tier 3 $500 Copay Specialty Tier 3 $500 Copay Specialty Tier 3 $500 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
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