Page 18 - QCS.19 Employee Benefits

2019 Medical Benefits

Medical PLAN
United Healthcare

You have the option to enroll in our group health insurance plan through United Healthcare.

The benefits and your cost ALL SAVERS - Health Savings Account HSA
(contribution) are outlined in the
adjacent table. Benefits In-Network Out-of-Network
Annual Deductible $2,850 / $5,700 $5,700/ $11,400
To check and see if your doctor is in Individual/Family
your plan click on: Out of Pocket Maximum $6,550 / $13,100 $11,400 / $22,800
UHC Provider Search Individual/Family
Select “Choice Plus” as your network Unlimited Unlimited
(The out of pocket includes the
When you receive your ID card in annual deductible)
the mail, use it to register for the
member website at: Lifetime Maximum
United Healthcare Member Site
Preventive Services Paid at 100% Deductible + 50%
You can learn more about your
coverage and track claims and PCP Office Visit $30 Copay Deductible + 50%
explanation-of-benefits statements
throughout the year. Specialist Office Visit $60 Copay Deductible + 50%

Urgent Care $100 Copay Deductible + 50%

Emergency $500 Copay

Inpatient Deductible + 0% Deductible + 50%

Outpatient Services Deductible + 0% Deductible + 50%

UHC Customer Service Mental Health - Inpatient Deductible + 0% Deductible + 50%
800-382-5729
Hours: Mental Health - Paid at 100% Deductible + 50%
Mon-Fri 8:00AM – 6:00PM CST Outpatient $30 Copay Deductible + 50%

Hourly Employees Short Term Rehabilitation The greater of $70
Coverage Election or 50%, min $70
Employee Only Outpatient
Employee + Spouse Not Covered
Employee + Child(ren) Prescriptions
Family
(Generic/Preferred/Non-Preferred)

Retail – 30 day supply $10/$35/$60/$100

Mail Order – 90 day $25/$88/$150/$250
supply

Refer to United Healthcare’s detailed plan summary for limitations

Monthly Bi-Weekly
$314.17 $145
$650.00 $300
$682.50 $315
$790.83 $365

For additional plan information, please refer to the detailed plan description provided by the carrier.
In the event of a discrepancy, the carrier Pan Document shall prevail.