Page 9 - Benefits Guide 2022 EPO

Medical Insurance UnitedHealthcare

The Buy-Up plan has a higher premium, offering a lower deductible, lower out-of-pocket maximum and
lower co-insurance. Yet, the Choice EPO Core plan has a lower premium offering the same benefit at in-
network only with a higher deductible, out-of-pocket maximum and co-insurance. There are benefits
to both plans but it is up to you to decide what coverage is best for you and your family. To locate a
network physician refer to the online provider directory at www.myuhc.com select UHC Choice Plus or
call Customer Service at 866-633-2446 for assistance.

Buy-Up Plan

Plan Features In-Network Out-of-Network

$1,000 Individual $1,000 Individual
Calendar Year Deductible $2,000 Family $2,000 Family
Coinsurance (Plan Pays) 80% 50%

Out of Pocket Maximum $4,000 Individual $5,000 Individual
(Includes Deductible and all Copays) $8,000 Family $10,000 Family
Lifetime Maximum Unlimited
Office Visit - Primary $25 copay per visit 50% after deductible

Office Visit - Under Age 19 $0 copay 50% after deductible
Office Visit - Specialist $25/$50 copay per visit 50% after deductible
Virtual Visit $0 copay per visit 50% after deductible
Preventive Care Services 100% 50% after deductible
Hospital and Other Charges
Inpatient 80% after deductible 50% after deductible
Outpatient 80% after deductible 50% after deductible
Emergency Room Charges $250 copay per visit, then 20%

Urgent Care $75 copay per visit 50% after deductible
Pharmacy
Retail (up to a 90 day supply) $10 / $35 / $60
Generic/Preferred Brand/Non-Preferred $10 / $35 / $60 Additional out of pocket expenses
Brand may apply
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 $130.06 $547.90
EE + SP $453.39 $858.59
EE + SP (SP Surcharge) $490.89 $858.59
EE + CH $311.28 $717.37
EE + FAM $623.59 $985.80
EE + FAM (SP Surcharge) $661.09 $985.80

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