Page 3 - Luminex 2021 BLUE Triangles 12pg Guide w_Notices V5 - 1-12-2021

MEDICAL COVERAGE -

UNITEDHEALTHCARE

MEDICAL BENEFITS AT-A-GLANCE AND COST OF COVERAGE

Each person’s health care needs are different. That’s why our medical plan offers multiple options so that you can choose the
coverage level best-suited to your personal situation. Note: coinsurance percentages and copays included in the chart below
represent the member responsibility.
$750/$1,500 $2,000/$4,000 $3,500/$7,000
BENEFIT DEDUCTIBLE PLAN DEDUCTIBLE PLAN DEDUCTIBLE PLAN
In-Network Out-Of-Network In-Network Out-Of-Network In-Network Out-Of-Network
Annual Calendar Year Deductible
Single $750 $1,500 $2,000 $4,000 $3,500 $7,000
Family $1,500 $3,000 $4,000 $8,000 $7,000 $14,000
UHC HSA Seeding - Motion Program
Employee Only N/A N/A Up to $1,150 Up to $1,150
Employee + Spouse N/A N/A Up to $2,300 Up to $2,300
Out-of-Pocket Maximum
Single $3,000 $6,000 $4,000 $8,000 $6,550 $10,000
$7,350 $16,000 $13,300 $20,000
Family $6,000 $12,000
Max for ind. $7,350 N/A Max for ind. $6,550 N/A
Lifetime Maximum N/A N/A N/A
Coinsurance 15% 35% 20% 40% 20% 40%
Physician Services
Doctor’s office visit $20 20% after ded 20% after ded 40% after ded 20% after ded 40% after ded
Specialist office visit $40 20% after ded 20% after ded 40% after ded 20% after ded 40% after ded
Preventive care No Charge 20% after ded No Charge 20% after ded No Charge 20% after ded
Lab and X-ray Services 15% after ded 35% after ded 20% after ded 40% after ded 20% after ded 40% after ded
Hospital Services
Inpatient 15% after ded 35% after ded 20% after ded 40% after ded 20% after ded 40% after ded
Outpatient 15% after ded 35% after ded** 20% after ded 40% after ded 20% after ded 40% after ded
Emergency Care 15% after ded 15% after ded 20% after ded 20% after ded 20% after ded 20% after ded
PRESCRIPTION DRUGS
Deductible – Ind/Fam $100/$300 Combined with Medical Combined with Medical
Out-of-Pocket Max – Ind/Fam $3,000/$6,000 N/A Combined with Combined with Combined with Combined with
Medical Medical Medical Medical
Retail (30-day supply)
Generic $10 copay, no ded $10 copay, no ded
Preferred brand $35 copay after ded $35 copay after ded $0 copay after ded $0 copay after ded $0 copay after ded $0 copay after ded
Non-preferred brand $70 copay after ded $70 copay after ded
Mail Order (90-day supply)
Generic $25 copay, no ded
Preferred brand $87.50 copay after Not Covered $0 copay after ded Not Covered $0 copay after ded Not Covered
ded
$175 copay after
Non-preferred brand
ded
BI-WEEKLY PAYCHECK DEDUCTIONS
Employee Only $188.31 $92.08 $33.54
Employee + Spouse* $449.73 $245.28 $122.34
Employee + Child(ren) $357.79 $174.95 $63.73
Family $600.37 $318.94 $149.18
Note: Deductibles, copays and coinsurance accumulate toward the out-of-pocket maximums. Usual, Customary and Reasonable charges apply for all out-of-network
benefits. For a complete listing of services covered by your medical plan, please refer to the summary of benefits provided by your plan administrator. Note: If you
self-report as a tobacco user, the surcharge will appear as a separate payroll deduction.
*Spousal surcharge included. 3
**20% after deductible for outpatient habilitative services.