Page 4 - Wesco Benefit Guide Effective 9-1-2021

Medical Options:

United Healthcare

Effective 9-1-2021 CE-D4 CE-D2
Weekly Per Pay Period
We offer our full-time employees and their
Employee Only $ 26.44 $ 37.33 eligible dependents coverage. Children
can join or remain on a parent’s medical
Employee + Spouse $132.27 $154.04 plan until age 26. When a child turns 26,
Employee + Child(ren) $132.27 $154.04 they will lose medical coverage on the last
day of their birth month.
Employee + Family $238.10 $270.75

Brief Member Charter CE-D4 Primary Charter CE-D9 Primary
Advantage HMO Silver
Advantage HMO Gold
In-Network Summary IN-NETWORK ONLY IN-NETWORK ONLY

Network Charter HMO Charter HMO

(CYD) Calendar Year Deductible Individual: $6,000 Individual: $2,500
(Jan .1st to Dec. 31st) Family: $12,000 Family: $5,000

Coinsurance Carrier 70% Carrier: 80%
(After CYD Calendar Year Deductible) Member: 30% Member: 20%

Individual: $8,500 Individual: $8,500
Annual (OOP) Out of Pocket Maximum
Family: $17,000 Family: $17,000
(PCP) Primary Care Physician $0 Copay $0 Copay
(Dr. Services Only)
$70 Copay (you must have a referral $70 Copay (you must have a referral
Specialist Physicians and Providers from your PCP) Not needed for (OB/GYN’s)., from your PCP) Not needed for (OB/GYN’s).,
(Dr. Services Only) Urgent Care, Behavioral health or use Urgent Care, Behavioral health or use
disorder clinicians. disorder clinicians.

Dr. Consultation - Virtual Visits, See Pg. 7 $0 Copay $0 Copay

Basic: Lab, X-Rays & Diagnostic Basic: 30% after CYD Basic: 20% after CYD
Major: Diagnostic & Imaging Major: 30% after CYD Major: 20% after CYD

Annual Preventive Care Certain Rx are covered Covered 100% Covered 100%
too, See Page 5 (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)

p
o
ay
$50 copay (Dr. Services Only) ervices Only)
$50 c
r
. S
D
(
Urgent Care
(CYD apply to other services) (CYD apply to other services)
Emergency Room $250 Copay plus 30% after CYD $250 Copay plus 20% after CYD
Hospitalization:
30% after CYD 20% after CYD
In Patient/ Outpatient
Tier 1 $10 Copay Tier 1 $10 Copay
Prescription Drugs - 31 Day Supply Retail Tier 2 $40 Copay Tier 2 $40 Copay
90 Day Supply Mail Order at 2.5 Times Retail Tier 3 $125 Copay Tier 3 $125 Copay
Tier 4 $300 Copay Tier 4 $300 Copay

4 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, for Charter Network