Page 5 - Phil Chai - Benefit Guide Twin City Gardens 10-15-2021

Medical Options:

United Healthcare (UHC)

ProFormance
Effective 3/1/2021 Premier Premier We offer our full-time employees and their eligible
Bi-Weekly Pay Period AXKY-IU BCZ2-IU BCZS-IU
dependents coverage. Children can join or remain
Employee Only $ 94.52 $118.25 $179.89 on a parent’s medical plan until age 26. When a
Employee + Spouse $310.14 $444.17 $601.99 child turns 26, they will lose medical coverage on the
Employee + Child(ren) $251.28 $333.03 $497.54 last day of their birth month.
Employee + Family $454.60 $760.77 $989.32

ProFormance AXKY Premier BCZ2 Premier BCZS
Brief Member $3,000 Deductible $3,000 Deductible
$5,000 Deductible
Network Summary IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY
Covered 100% Covered 100% Covered 100%
COVID-19 Testing & Vaccine COVID period)
(No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
Network CHOICE CHOICE CHOICE
(CYD) Calendar Year Deductible (Jan .1st to Individual: $5,000 Individual: $3,000 Individual: $3,000
Dec. 31st) Family: $10,000 Family: $6,000 Family: $6,000
Coinsurance Carrier: 80% Carrier: 80% Carrier: 100%
(After CYD) Member: 20% Member: 20% Member: 0%

Individual: $7,150 Individual: $6,000 Individual: $4,500
Annual (OOP) Out of Pocket Maximum
Family: $14,300 Family: $12,000 Family: $9,000
Under Age 19: $0 Copay Under Age 19: $0 Copay Under Age 19: $0 Copay
Primary Care Physician (PCP)
Age 19 & Over: $15 Copay Age 19 & Over: $30 Copay Age 19 & Over: $30 Copay
UHC Network Providers UHC Network Providers UHC Network Providers
Specialist Physicians and Non PCP Providers $50 Copay -Designated $30 Copay -Designated $30 Copay -Designated
$100 Copay -Standard $60 Copay -Standard $60 Copay -Standard

Dr. Consultation Virtual Visits (Telehealth) see $0 Copay $0 Copay $0 Copay
page 7&8

Basic: Lab, X-Rays / Diagnostic Major: Basic: 20% after CYD Basic: Paid 100% Basic: Paid 100%
Diagnostic & Imaging Major: 20% after CYD Major: 20% after CYD Major: Paid 100% after CYD

Annual Preventive Care (Certain Rx are Covered 100% Covered 100% Covered 100%
covered too) See page 4 (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)

$25 Copay (Dr. Services Only)
Urgent Care $75 Copay $75 Copay
(CYD/20% apply to other services)
20% after $250 Copay $300 Copay
Emergency Room $300 Copay, after CYD and 20%
CYD does not apply CYD does not apply
Hospitalization: (In / Outpatient) 20% after CYD 20% after CYD Paid 100% after CYD

RX Plan IU RX Plan IU RX Plan IU
Prescription Drugs - 31 Day Supply Retail Tier 1 $15 Copay Tier 1 $15 Copay Tier 1 $15 Copay
90 Day Supply Mail Order at 2.5 Times Retail Tier 2 $40 Copay Tier 2 $40 Copay Tier 2 $40 Copay
Tier 3 $75 Copay Tier 3 $75 Copay Tier 3 $75 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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