Page 7 - 61st Street Service Corp. | 2020 EPIC Benefits Guide

Medical Plan
Administered by UnitedHealthcare
61st Street Service Corporation offers employees and their families an HRA medical plan through UnitedHealthcare. Please review the benefits below. DEPENDENT ELIGIBILITY: Eligible dependents include your spouse and dependent children until the child reaches age 26. Benefits discontinue at the end of the year in which the child turns 26.
UnitedHealthcare Choice Plus
(844) 637 – 7501
www.myuhc.com
Prescription Drug Plan
Optum Rx
(888) 290 – 5416 www.optumrx.com
Your preventive care visits are covered at 100%
Summary of 2020 Medical Plan Benefits* & Costs
HRA 1500 Plan
In-Network
Out-of-Network
$4,000 / $8,000
$7,000 / $14,000
20% after deductible
40% after deductible
40% after deductible
Calendar Year Deductible (Individual/Family)
Out-of-Pocket Maximum**** (Individual/Family)
Emergency Room
Lab & X-ray
Mental Health/Substance Abuse
$1,500 / $3,000
$2,500 / $4,500
20% after deductible
No charge at participating labs (LabCorp)
20% after deductible
Member Coinsurance
20%
40%
Preventive Care
Covered 100%
Adult: Not covered Children: 40% after deductible
Office Visits
20% after deductible
40% after deductible
Hospital Services (Inpatient & Outpatient**)
20% after deductible
40% after deductible
Urgent Care
20% after deductible
40% after deductible
Maternity Care**
Prenatal and Post-Natal Care, Hospital Services for Mother and Child
20% after deductible
40% after deductible
Prescription Drugs*** (Up to a 30-day supply)
• Generic
• Preferred Brand Name
• Non-Preferred Brand Name.
Up to $15 $35 $75
Not covered
*2020 HRA employer funding: $500 Employee Only — $750 Employee Plus 1 — $1,200 Employee Plus 2 or more.
**These services require precertification through UnitedHealthcare
***Prescription medications ordered through the Mail Order Drug Program are subject to 2 1/2 applicable retail pharmacy copays ****Copays, deductible & coinsurance CAP per Healthcare Reform guideline
Benefits of Staying In-network
Our medical, dental and vision programs offer both in-network and out-of-network benefits to employees. However, to take advantage of carrier discounts and to save money, make sure to utilize in-network providers. When employees go out-of-network, they can be balance billed for amounts over and above what insurance will pay. To find in-network providers, search carrier websites or call them at the numbers indicated on their respective pages in this guide.
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