Page 8 - Benefits Guide 2022 EPO

Medical Insurance UnitedHealthcare

Mission is committed to providing you with comprehensive medical benefits to meet your needs. We will
continue to offer two medical programs. Regardless of which program you choose, you pay the cost of
your coverage through pre-tax payroll deductions. By paying on a pre-tax basis, your cost for coverage is
lower because the earnings you use to pay premiums are not subject to federal tax withholding or Social
Security (FICA) taxes. UnitedHealthcare administers the medical and prescription drug plans. To locate a
network physician, refer to the online provider directory at www.myuhc.com. Select UHC Choice or call
customer service at 866-633-2446 for assistance.
IMPORTANT NOTICE: Only in-network services are covered under the Choice EPO Plan.

Choice EPO Plan

Plan Features In-Network Out-of-Network
$2,000 Individual
Calendar Year Deductible Not Covered
$4,000 Family
Coinsurance (Plan Pays) 70% Not Covered
Out of Pocket Maximum $6,000 Individual Not Covered
(Includes Deductible and all Copays) $12,000 Family
Lifetime Maximum Unlimited
Office Visit - Primary $30 copay per visit Not Covered

Office Visit - Under Age 19 $0 copay Not Covered
Office Visit - Specialist $30/$60 copay per visit Not Covered
Virtual Visit $0 copay per visit Not Covered
Preventive Care Services 100% Not Covered
Hospital and Other Charges
Inpatient 70% after deductible Not Covered
Outpatient 70% after deductible Not Covered
Emergency Room Charges $250 copay per visit, then 30%
Urgent Care 100% after $75 copay per visit Not Covered
Pharmacy
Retail (up to a 90 day supply)
Generic/Preferred Brand/Non-Preferred $10 / $35 / $60 Not Covered
Brand
Mail (up to a 90 day supply)
Generic/Preferred Brand/Non-Preferred $25 / $87.50 / $150 Not Covered
Brand

Semi-Monthly Contributions

Election Full- Time Employees Part-Time Employees
EE $42.16 $446.15
EE + SP $294.21 $699.08
EE + SP (SP Surcharge) $331.71 $699.08
EE + CH $181.69 $584.11
EE + FAM $396.33 $802.58
EE + FAM (SP Surcharge) $433.83 $802.58

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