Page 4 - Pampa 2024 Benefit Guide Final
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Medical Options:


          United Healthcare (UHC)




            24 Pay Periods       Platinum PPO   Gold PPO   Silver PPO   We offer  our full-time employees and their
                                  CVAS/K35Y   CWEE/K35Y   CV4X/K35Y
                                                                        eligible  dependents  coverage.  Children
         Employee Only            $185.00    $135.00    $  95.00        can  join  or  remain  on  a  parent’s  medical
         Employee + Spouse        $550.00    $400.00    $350.00         plan  until  age  26.    When  a  child  turns  26,
                                                                        they will lose medical coverage on the last
         Employee + Child(ren)    $550.00    $400.00    $350.00
                                                                        day of their birth month.
         Employee + Family        $850.00    $650.00    $550.00

                                       Platinum PPO—CVAS             Gold PPO— CWEE           Silver PPO—CV4X
                Brief Member                     $250 Deductible   $2,500  Deductible         $6,000 Deductible
            In-Network Summary
                                        IN & OUT OF NETWORK        IN & OUT OF NETWORK       IN & OUT OF NETWORK
          Network                       Choice Plus—Nationwide     Choice Plus—Nationwide      CHOICE—Nationwide
          (CYD) Calendar Year Deductible   Individual: $250          Individual: $2,500         Individual: $6,000
          (Jan .1st to Dec. 31st)            Family: $750             Family: $7.500             Family: $12,000
          Coinsurance:
                                             Carrier: 80%                                       Carrier: 80%                                       Carrier: 80%
          After Calendar Year Deductible
                                            Member: 20%                Member: 20%               Member: 20%
          CYD)
          Annual (OOP) Out of Pocket       Individual: $1,250        Individual: $7,000         Individual: $9.100
          Maximum                           Family: $3,750            Family: 14,000             Family: $18,200

                                         Under Age 19: $0 Copay                   Under Age 19: $0 Copay                   Under Age 19: $0 Copay
          Primary Care Physician (PCP)
                                         Over Age 19: $15 Copay    Over Age 19: $10 Copay     Over Age 19: $35 Copay
                                        UHC Network Providers      UHC Network Providers      UHC Network Providers
          Specialist Physicians and Non
                                         $50Copay -Designated      $40Copay -Designated       $70Copay -Designated
          PCP Providers
                                         $100 Copay -Standard       $80 Copay -Standard       $100 Copay -Standard
          Dr. Consultation Virtual Visits
                                              $0 Copay                  $0 Copay                   $0 Copay
          (Telehealth)
          Basic: Lab, X-Rays & Diagnostic/                       Basic:  $40 Copay CYD Waived
                                            20% after CYD                                        20% after CYD
          Major: Diagnostic & Imaging                               Major:  20% after CYD
          Annual Preventive Care (Certain   Covered 100%                                       Covered 100%                                       Covered 100%
          Rx are covered too)           (No CYD, Co-Ins. Copays)   (No CYD, Co-Ins. Copays)   (No CYD, Co-Ins. Copays)
                                             $50 Copay                                                  $25 copay                                            $25 copay
          Urgent Care
                                         (others charges may apply)   (others charges may apply)   (others charges may apply)
          Emergency Room              $300 Copay, after CYD and 20%    $300 Copay, after CYD and 20%    $300 Copay, after CYD and 20%
          Hospitalization:
                                            20% after CYD              20% after CYD             20% after CYD
          (In / Outpatient)
                                           Tier 1 $10 Copay                                   Tier 1 $10 Copay                                    Tier 1 $10 Copay
          Drug Plan—K35Y                   Tier 2 $40 Copay                                    Tier 2 $40 Copay                                    Tier 2 $40 Copay
          Prescription Drugs - 31 Day Sup-  Tier 3 $125 Copay        Tier 3 $125 Copay          Tier 3 $125 Copay
          ply Retail                       Tier 4 $300 Copay         Tier 4 $300 Copay          Tier 4 $300 Copay
          90 Day Supply  Mail Order at 2.5   Specialty Drugs          Specialty Drugs            Specialty Drugs
          Times Retail                      Tier 1,2,3 Same           Tier 1,2,3 Same            Tier 1,2,3 Same
                                           Tier 4 $500 Copay         Tier 4 $500 Copay          Tier 4 $500 Copay


                                          CVS Pharmacy is NO longer in-network
              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        4
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