Page 4 - Adolph's Litho Services - Benefit guide - 2021

Medical Options:

United Healthcare

2021 Rate Information — Per Pay Period

Employee Employer Dependent Information
Per Pay Period
Weekly Cost Weekly Cost
Adolph’s Litho Services offers employees the
Employee Only $0.00 $180.55 opportunity to cover their spouse and

Employee + Spouse $25.00 $335.11 dependent children. Children can join or
remain on a parent’s plan until age 26. They
Employee + Child(ren) $25.00 $335.11 will lose medical coverage on the last day of
Employee + Family $25.00 $515.17 their birth month.

EPO — In Network Benefits Only
Summary of CEES w/E82 No Out Of Network Benefits with this Plan
$5,500 Deductible
Unless an EMERGENCY

Deductible – Calendar Year Deductible Individual: $5,500
(CYD) Family: $11,000

Coinsurance Carrier 100% / Member 0%

Individual: $7,900
Annual Out of Pocket Maximum
Family: $15,800
Office Visit - Primary Care Physician (PCP) Under Age 19: $0 Copay
No REFERRAL NEEDED Age 19 and Over: $30 Copay
Virtual Designated Network Providers $0 Copay
(Telehealth) See Page 6 For More Details
$30 Copay (Designated Network)
Office Visit - Specialist
$60 Copay (Network)
Preventive Care Covered at 100%

Labs / X-rays Covered at 100%

MRI’s / PT’s / CT’s, Etc. (No CYD) $400 Copay

Urgent Care $50 Copay
$350 Copay
Emergency Room Copay
Out of Network Emergency Room $350 Copay
Hospital: Paid 100% After CYD
• Inpatient Paid 100% After CYD
• Outpatient
Tier 1:$10 Copay
Prescription Drugs—31 Day Supply Retail Tier 2:$40 Copay
(90 Day Mail Order at 2.5 Times Retail Tier 3:$125 Copay
Copay)
Tier 4:$300 Copay

NOTE: This is only intended as a brief overview. Please see Benefit Summary or contact United Healthcare for more details.
Support Tools @ www.myuhc.com or Customer Service @ 866-633-2446
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