Page 5 - Phil Chai - Benefit Guide Stamford Residence & Rehabilitation 3-1-2022

Medical Options:

United Healthcare (UHC)

Navigate
Effective 3/1/2022 ProFormance Premier Premier We offer our full-time employees and their eligible
Bi-Weekly Pay Period AYZB-G58Y AXKY-G58Y BCZ2-G58Y BCZS-G58Y
dependents coverage. Children can join or remain
Employee Only $ 72.41 $ 94.52 $118.25 $179.89 on a parent’s medical plan until age 26. When a
Employee + Spouse $256.62 $310.14 $444.17 $601.99 child turns 26, they will lose medical coverage on the
Employee + Child(ren) $211.26 $251.28 $333.03 $497.54 last day of their birth month.
Employee + Family $380.97 $454.60 $760.77 $989.32

Navigate HMO AYZB $5,000 ProFormance AXKY Premier BCZ2 Premier BCZS
Brief Member $5,000 Deductible $5,000 Deductible $3,000 Deductible $3,000 Deductible
Network Summary IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY
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COVID-19 Testing & Vaccine Covered 100% Covered 100% overed 100% ered 100%
COVID period) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
Network Navigate “TEXAS” Only CHOICE CHOICE CHOICE
(CYD) Calendar Year Deductible Individual: $5,000 Individual: $5,000 Individual: $3,000 Individual: $3,000
(Jan .1st to Dec. 31st) Family: $10,000 Family: $10,000 Family: $6,000 Family: $6,000
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Coinsurance Carrier: 100% arrier: 80% rier: 80% arrier: 100%
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(After CYD) Member: 0% Member: 20% Member: 20% Member: 0%
Annual (OOP) Out of Pocket Individual: $7,350 Individual: $7,150 Individual: $6,000 Individual: $4,500
Maximum Family: $14,700 Family: $14,300 Family: $12,000 Family: $9,000
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: $15 Copay Age 19 & Over: $30 Copay Age 19 & Over: $30 Copay
$60 Copay (you must have a UHC Network Providers UHC Network Providers UHC Network Providers
Specialist Physicians and Non referral from your PCP) Not needed for $50 Copay -Designated $30 Copay -Designated $30 Copay -Designated
PCP Providers (OB/GYN’s)., Urgent Care, Behavioral health or
use disorder clinicians. $100 Copay -Standard $60 Copay -Standard $60 Copay -Standard
Dr. Consultation Virtual Visits $0 Copay $0 Copay $0 Copay $0 Copay
(Telehealth) see page 6&7
Basic: Lab, X-Rays / Diagnostic Basic: $40 Copay CYD Waived Basic: 20% after CYD Basic: Paid 100% Basic: Paid 100%
Major: Diagnostic & Imaging Major: $500 Copay Major: 20% after CYD Major: 20% after CYD Major: Paid 100% after CYD
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Annual Preventive Care (Certain Covered 100% Covered 100% overed 100% ered 100%
Rx are covered too) See page 4 (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/20% apply to other services)
20% after $250 Copay $300 Copay
Emergency Room $500 Copay, after CYD $300 Copay, after CYD and 20%
CYD does not apply CYD does not apply
Hospitalization: Paid 100% after CYD 20% after CYD 20% after CYD Paid 100% after CYD
(In / Outpatient)
RX Plan G58Y RX Plan G58Y RX Plan G58Y RX Plan G58Y
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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