Page 5 - 2022 Stamford Benefit Guide 5-1-2022

Medical Options:

United Healthcare (UHC)

g
avi
N
Effective 51/2022 ate PROFormance PROformance
We offer our full-time employees and their eligible
Bi-Weekly Pay Period CEGD-K35Y CEF2-K35Y CEFX-K35Y
dependents coverage. Children can join or remain
Employee Only $ 77.02 $ 94.52 $109.02
on a parent’s medical plan until age 26. When a
Employee + Spouse $256.62 $287.06 $388.03 child turns 26, they will lose medical coverage on the
Employee + Child(ren) $229.72 $260.51 $333.03 last day of their birth month.
Employee + Family $380.97 $431.52 $576.16
Navigate HMO CE-GD ProFormance CE-F2 ProFormance CE-FX
Brief Member $3,500 Deductible $3,000 Deductible
$3,500 Deductible
Network Summary IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY

Network Navigate “TEXAS” Only CHOICE CHOICE
(CYD) Calendar Year Deductible Individual: $3,500 Individual: $3,500 Individual: $3,000
(Jan .1st to Dec. 31st) Family: $7,000 Family: $7,000 Family: $6,000
Coinsurance Carrier: 80% Carrier: 80% Carrier: 80%
(After CYD) Member: 20% Member: 20% Member: 20%
Individual: $8,500 Individual: $8,500 Individual: $8,500
Annual (OOP) Out of Pocket Maximum
Family: $17,000 Family: $17,000 Family: $17,000
n
Under Age 19: $0 Copay Under Age 19: $0 Copay der Age 19: $0 Copay
U
Primary Care Physician (PCP)
Age 19 & Over: $15 Copay Age 19 & Over: $15 Copay Age 19 & Over: $10 Copay
$50 Copay -Designated
Specialist Physicians and Non PCP $100 Copay -Standard $50 Copay -Designated $40 Copay -Designated
Providers: you must have a referral from your PCP) $100 Copay -Standard $80 Copay -Standard
Designated or Non Designated Not needed for (OB/GYN’s)., Urgent Care, Behavioral health or
use disorder clinicians.

Dr. Consultation Virtual Visits $0 Copay $0 Copay $0 Copay
(Telehealth) see page 6&7

Basic: Lab, X-Rays / Diagnostic Major: Basic: 20% after CYD Basic: 20% after CYD Basic: $40 Copay CYD Waived
Diagnostic & Imaging Major: 20% after CYD Major: 20% after CYD Major: $500 Copay

r
C
o
v
e
Annual Preventive Care (Certain Rx are Covered 100% Covered 100% ed 100%
covered too) See page 4 (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
$25 Copay 25 Copay 25 Copay
$
$
Urgent Care
(CYD apply to other services, e.g. Surgery) (CYD apply to other services, e.g. Surgery) (CYD apply to other services, e.g. Surgery)
Emergency Room $300 Copay, after CYD and 20% $300 Copay, after CYD and 20% $300 Copay, after CYD and 20%
Hospitalization: 20% after CYD 20% after CYD 20% after CYD
(In / Outpatient)
RX Plan RX Plan RX Plan
Prescription Drugs - 31 Day Supply Tier 1 $10 Copay, Specialty $10 Copay pecialty $10 Copay pecialty $10 Copay
1
0
p
0
$

,
1
r
y
T
o
p
C
a

C
o
$

ie
S
y
S
,
r
1
T

ie

a
1

Retail Tier 2 $40 Copay, Specialty $40 Copay pecialty $40 Copay pecialty $40 Copay

S

0
,
$
4
a
y

p

r
y
a
r
2
ie
T

S
ie
,

o

C
o
T
C
4
$

2
0
p
90 Day Supply Mail Order at 2.5 Times Tier 3 $125 Copay, Specialty $125 Copay cialty $125 Copay cialty $125 Copay
3

$
,
y
a

e
p
S
5
2
1

p
o
C

$
,
r
ie
C
S
a

p
3

y
o
p

1
ie
r
5

e
2
T
T
Retail
3
$

p
a
Tier 4 $300 Copay, Specialty $500 Copay cialty $500 Copay cialty $500 Copay

T
e
p
S
y

4
,
ie
r
S
p
e
,

3
$
r
4

T
ie

C
C
0
o
0
o
y
a
0
0

p
Find Provider number 855-828-7715 800-782-3158 800-782-3158
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
5