Page 4 - Pump Down Specialist FINAL Benefit Guide 9-1-2024

Medical Options:

United Healthcare

UHC Medical:
DHMU
DHMU
DHMU w/Care Cash Semi-Monthly (24) Bi-Weekly (26)
9/1/2024 We offer our full-time employees and
their eligible dependents coverage.
Employee Only $ 0.00 $ 0.00 Children can join or remain on a
parent’s medical plan until age 26.
Employee + Spouse $406.43 $375.16
When a child turns 26, they will lose
Employee + Child(ren) $406.43 $375.16 medical coverage on the last day of
their birth month.
Employee + Family $812.85 $750.32
Brief Member (UHC) - DHMU/K35S w/Care Cash
In-Network Summary IN-NETWORK ONLY
Network CHOICE (EPO)

(CYD) Calendar Year Deductible Individual: $3,000
(Jan .1st to Dec. 31st) Family: $9,000

Coinsurance Carrier: 80%
(After CYD) Member: 20%
Annual (OOP) Out of Pocket Individual: $7,000
Maximum Family: $14,000

$0 Copay under Age 19
(PCP) Primary Care Physician
$10 Copay Adults; No CYD
$40 Copay Designated Network Provider; No CYD
Specialist Physicians and Providers
$80 Copay Network Provider; No CYD
Dr. Consultation
Virtual Visits $0 Copay; No CYD

Basic: Lab, X-Rays & Diagnostic/ Lab/Xray: $40 Copay/service; No CYD
Major: Diagnostic & Imaging MRI: 20% After CYD

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

Urgent Care $25 Copay; No CYD

Emergency Room $300 Copay + 20% after CYD

Hospitalization: In / Outpatient 20% after CYD

Tier I: $10 Copay; No CYD
Prescription Drugs Tier II: $40 Copay; No CYD
31 Day Supply Retail Tier III: $125 Copay; No CYD
90 Day Supply Mail Order at 2.5x Retail Tier IV: $300 Copay; No CYD
Specialty: $10/$40/$125/$500
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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