Page 4 - Megatel Homes LLC Benefit Guide Effective 8-1-2023 Updated 10-9-23

Medical Options:

United Healthcare

2023 H.S.A Plan HMO Value Premier
Effective 8-1-23 Plan A Plan B Plan
Bi-Weekly (26) Per Pay Period DDZZ-MM CZWA-IU BC2A-IU BCZ2-IU We offer our full-time employees and
their eligible dependents coverage.
Employee Only $ 46.46 $ 72.63 $ 92.52 $132.13 Children can join or remain on a
parent’s medical plan until age 26.
Employee + Spouse $247.21 $313.28 $363.48 $463.50
When a child turns 26, they will lose
Employee + Child(ren) $194.46 $247.09 $287.07 $366.73 medical coverage on the last day of
their birth month.
Employee + Family $323.63 $414.47 $483.48 $620.99

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Brief Member H.S.A Plan DDZZ Navigate HMO CZWA Premier Value BC2A emier BCZ2
In-Network $6,350 Deductible $5,000 Deductible $5,000 Deductible $3,000 Deductible
Summary IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY
PREMIER option with NO Specialist
LOW COST HMO option with FIRST Dollar
Referral Required. FISRT Dollar
Difference Between HSA-Compatible High Deductible coverage with Copays (CYD Waived) on MID-RANGE option with NO Specialist coverage with Copays (CYD Waived)
Plans Health Plans (HDHP) MOST Day to Day Services. Referral Re- Referral Required. Lower OOP on MOST Day to Day Services Lower
quired for Specialist
CYD / OOP
Network CHOICE Navigate “TEXAS—Only” CHOICE CHOICE
(CYD) Calendar Year Individual: $6,350 Individual: $5,000 Individual: $5,000 Individual: $3,000
Family: $12,700 Family: $10,000 Family: $10,000 Family: $6,000
Deductible (Jan .1st to Dec. 31st)
Coinsurance Carrier: 100% Carrier: 100% Carrier: 80% Carrier: 80%
(After CYD) Member: 0% Member: 0% Member: 20% Member: 20%
Annual (OOP) Out of Individual: $6,350 Individual: $7,350 Individual: $6,350 Individual: $6,000
Pocket Maximum Family: 12,700 Family: 14,700 Family: $12,700 Family: $12,000
(PCP) Primary Care 0% after CYD Under Age 19: $0 Copay Under Age 19: $0 Copay Under Age 19: $0 Copay
Physician Over Age 19: $10 Copay Over Age 19: $45 Copay Over Age 19: $30 Copay
$60 Copay (you must have a
Specialist Physicians referral from your PCP) Not UHC Network Providers UHC Network Providers
and Providers 0% after CYD needed for (OB/GYN’s)., Urgent Care, $45 Copay -Designated $30 Copay -Designated
Behavioral health or use $90 Copay -Standard $60 Copay -Standard
disorder clinicians.
Dr. Consultation Member Pays $49 Cost $0 Copay $0 Copay $0 Copay
Virtual Visits, See Pg. 8 Per Consultation
Basic: Lab, X-Rays & Basic: $40 Copay CYD Waived Basic: 20% after CYD Basic: Paid 100%
Diagnostic/Major: 0% after CYD
Diagnostic & Imaging Major: $500 Copay Major: $400 Copay Major: 20% after CYD
Annual Preventive
Covered 100% Covered 100% Covered 100% Covered 100%
Care Certain Rx are (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
covered too, See Page 5
$100 co
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$25 copay (Dr. Services Only) y)
Urgent Care 0% after CYD $75 Copay
(CYD apply to other services) (CYD/20% apply to other services)
20% after $400 Copay 20% after $250 Copay
Emergency Room 0% after CYD $500 Copay, after CYD
CYD does not apply CYD does not apply
Hospitalization: 0% after CYD 20% after CYD /
0% after CYD 20% after CYD
In / Outpatient (you must have a referral from your PCP) $250 Copay Applies
Prescription Drugs -
RX Plan MM RX Plan IU RX Plan IU RX Plan IU
31 Day Supply Retail Tier 1 $15 Copay r 1 $15 Copay r 1 $15 Copay
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90 Day Supply Mail 0% after CYD Tier 2 $40 Copay r 2 $40 Copay r 2 $40 Copay
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Order at 2.5 Times Tier 3 $75 Copay Tier 3 $75 Copay Tier 3 $75 Copay
Retail
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 Navigate 855-828-7715 , for H.S.A 866-314-0335