Page 4 - Pampa 2024 Benefit Guide Final

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