Page 4 - IFC Roofing Benefit Guide Jan 1 to Dec 31 2021

Medical Options:

United Healthcare (UHC)

For your Pre-Taxed costs per pay period We offer our full-time employees and their eligible
dependents coverage. Children can join or remain on
please see rates when you enroll online. a parent’s medical plan until age 26. When a child
turns 26, they will lose medical coverage on the last
day of their birth month.

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Summary of Plan OOD PLAN BETTER PLAN BEST PLAN
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In-Network Benefits and Charter Gold CE-D2 Choice Gold CE-F4 ice Platinum CE-FN
Member Costs $2,500 Deductible $4,000 Deductible $1,,000 Deductible
Charter HMO Network
UHC Network Choice Network Choice Network
DFW—Only
(CYD) Calendar Year Deductible Individual: $2,500 Individual: $4,000 Individual: $1,000
January 1st to December 31st Family: $5,000 Family: $8,000 Family: $2,000

Coinsurance Carrier: 80% / Member: 20% Carrier: 80% / Member: 20% Carrier: 80% / Member: 20%
Calendar Year Annual Out of
Individual: $8,500 Individual: $8,500 Individual: $2,500
Pocket Maximum (Copays, CYD
Family: $17,000 Family: $17,000 Family: $5,000
Deductibles and Coinsurance)
$0 Copay -Under Age 19: $0 Copay -Under Age 19: $0 Copay -Under Age 19:
(PCP) Primary Care Physician
$0 Copay -Age 19 or Older $10 Copay -Age 19 or Older $10 Copay -Age 19 or Older

$70 Copay (must have a referral Network Providers Network Providers
from your PCP) Not needed for (OB/
Specialist Physicians & Providers $40 Copay -Designated $40 Copay -Designated
GYN’s)., Urgent Care, Behavioral health or
use disorder clinicians. $80 Copay -Standard $80 Copay -Standard

Dr. Consultation Virtual Visits $0 Copay $0 Copay $0 Copay

Basic: Lab, X-Rays & Diagnostic / Basic: 20% after CYD Basic: $40 Copay, No CYD Basic: $40 Copay
Major: Diagnostic & Imaging Major: 20% after CYD Major: $500 Copay No CYD Major: $500 Copay, No CYD
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Preventive Care (Certain Rx are Covered 100% vered 100% ered 100%
covered too) (No CYD, Co-Ins. Copay) (No CYD, Co-Ins. Copay) (No CYD, Co-Ins. Copay)
$50 copay $25 copay $25 copay
Urgent Care
(CYD may apply to other services) (CYD may apply to other services) (CYD may apply to other services)
Emergency Room $250 Copay plus 20% after CYD $300 Copay plus 20% after CYD $300 Copay plus 20% after CYD
Hospitalization:
20% after CYD 20% after CYD 20% after CYD
In / Out Patient
Exams, Lenses, Frames paid after Exams, Lenses, Frames paid after Exams, Lenses, Frames paid after
Vision—Pediatric Only to Age 19
Copays up to plan limits Copays up to plan limits Copays up to plan limits
Prescription Drugs :
Tier 1 $10 Copay Tier 1 $10 Copay Tier 1 $10 Copay
31 Day Supply Retail
Tier 2 $50 Copay Tier 2 $50 Copay Tier 2 $50 Copay
90 Day Supply Mail Order at 2.5
Tier 3 $125 Copay Tier 3 $125 Copay Tier 3 $125 Copay
Specialty Drugs (same as other
Tier 4 $300 Copay Tier 4 $300 Copay Tier 4 $300 Copay
Tiers)
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 UHC EPO 866-633-2446, Charter Plans 855-828-7715
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