Page 4 - Revelations Healthcare - Benefit Guide 2020 R9-20

Medical Options:

United Healthcare (UHC)

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Effective 1-1-2020 /HMO ProFormance Premier We offer our full-time employees and
Bi-Weekly Pay Period AYZL-IU AXKY-IU BCZ2-IU
their eligible dependents coverage.
Employee Only $ 63.00 $ 86.40 $142.01 Children can join or remain on a
Employee + Spouse $381.84 $433.31 $555.66 parent’s medical plan until age 26.
When a child turns 26, they will lose
Employee + Child(ren) $336.83 $380.10 $483.00
medical coverage on the last day of
Employee + Family $645.61 $720.48 $898.44 their birth month.

Navigate HMO AYZL ProFormance AXKY Premier BCZ2
Brief Member $5,000 Deductible $5,000 Deductible $3,000 Deductible
In-Network Summary IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY

Network Navigate “TEXAS—Only” CHOICE CHOICE
(CYD) Calendar Year Deductible Individual: $5,000 Individual: $5,000 Individual: $3,000
(Jan .1st to Dec. 31st) Family: $10,000 Family: $10,000 Family: $6,000
Coinsurance Carrier: 80% Carrier: 80% Carrier: 80%
(After CYD) Member: 20% Member: 20% Member: 20%
Annual (OOP) Out of Pocket Individual: $7,350 Individual: $7,150 Individual: $6,000
Maximum Family: 14,700 Family: $14,300 Family: $12,000
Under Age 19: $0 Copay Under Age 19: $0 Copay Under Age 19: $0 Copay
Primary Care Physician (PCP)
Over Age 19: $10 Copay Over Age 19: $15 Copay Over Age 19: $30 Copay
$60 Copay (you must have a UHC Network Providers UHC Network Providers
Specialist Physicians and Non referral from your PCP) Not needed for
PCP Providers (OB/GYN’s)., Urgent Care, Behavioral health or $50 Copay -Designated $30 Copay -Designated
use disorder clinicians. $100 Copay -Standard $60 Copay -Standard

COVID Testing and Treatment Covered 100% Covered 100% Covered 100%
(during COVID period) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
Dr. Consultation Virtual Visits $0 Copay $0 Copay $0 Copay
(Telehealth)
Basic: Lab, X-Rays & Diagnostic/ Basic: $40 Copay CYD Waived Basic: 20% after CYD Basic: Paid 100%
Major: Diagnostic & Imaging Major: $500 Copay Major: 20% after CYD Major: 20% after CYD

Annual Preventive Care Covered 100% Covered 100% Covered 100%
(Certain Rx are covered too) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
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$25 copay (Dr. Services Only) s Only)
Urgent Care $75 Copay
(CYD/20% apply to other services) (CYD/20% apply to other services)
20% after $250 Copay
Emergency Room $500 Copay, after CYD and 20% $300 Copay, after CYD and 20%
CYD does not apply
Hospitalization: 20% after CYD 20% after CYD 20% after CYD
(In / Outpatient) (you must have a referral from your PCP)
Prescription Drugs - 31 Day RX Plan IU RX Plan IU RX Plan IU
Supply Retail Tier 1 $15 Copay Tier 1 $15 Copay Tier 1 $15 Copay
90 Day Supply Mail Order at Tier 2 $40 Copay Tier 2 $40 Copay Tier 2 $40 Copay
2.5 Times Retail 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, for Navigate 855-828-7715
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