Page 4 - QCS.19 Employee Benefits
P. 4
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 - PPO PLAN
(contribution) are outlined in the
adjacent table. Benefits In-Network Out-of-Network
Annual Deductible $2,500 / $5,000 $5,000 / $10,000
To check and see if your doctor is in Individual/Family
your plan click on: Out of Pocket Maximum $5,000 / $10,000 $10,000 / $20,000
UHC Provider Search Individual/Family
Select “Choice Plus” as your network Unlimited Unlimited
(The out of pocket includes the Deductible + 50%
When you receive your ID card in annual deductible) Deductible + 50%
the mail, use it to register for the Deductible + 50%
member website at: Lifetime Maximum Deductible + 50%
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
explanation-of-benefits statements
throughout the year. Specialist Office Visit $60 Copay
Urgent Care $100 Copay
Emergency $500 Copay
Inpatient Deductible + 0%
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 $15/$35/$75/$200
Mail Order – 90 day $38/$88/$188/$625
supply
Refer to United Healthcare’s detailed plan summary for limitations
Monthly Bi-Weekly
$400.83 $185.00
$758.33 $350.00
$769.17 $355.00
$920.83 $425.00
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.
