Page 3 - WIEUS 23OE Brochure

2023
Benefits Enrollment

UMR—MEDICAL AND PRESCRIPTION

DRUG PLAN

Wiese offers three medical plan options administered by UMR, a United Healthcare Company: Premium,
Economy, and Choice. For a detailed summary of your health benefits and coverage, please see the Summary
of Benefits documents located on People1st: Myself>My Company>Electronic Forms

2023 Medical Plan Options

Premium Plan Economy Plan Choice Plan
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $1,000 $2,000 $3,000 $6,000 $3,000 $6,000
Family $2,000 $4,000 $6,000 $12,000 $6,000 $12,000
Out-of-Pocket Maximum (includes deductible)
Individual $3,000 $6,000 $5,000 $10,000 $4,000 $8,000
Family $6,000 $12,000 $10,000 $20,000 $8,000 $16,000
Coinsurance
10% 40% 20% 50% 10% 40%
Copays
Primary Care 40% after 50% after 10% after 40% after
$15 $25
Physician deductible deductible deductible deductible
40% after 50% after 10% after 40% after
Specialist $35 $50
deductible deductible deductible deductible
40% after 50% after 40% after
Preventive Care Covered at 100% Covered at 100% Covered at 100%
deductible deductible deductible
Emergency 10% after 10% after
$200 $200 $200 $200
Room deductible deductible
40% after 50% after 10% after 40% after
Urgent Care $50 $50
deductible deductible deductible deductible
Pharmacy
Deductible N/A $100 per person Combined with medical deductible
Tier 1 $15 $15
10% after deductible; certain
Tier 2 $30 50% (minimum $40 50% (minimum
preventive medications are covered
Tier 3 $50 $40) $75 $50)
at 100% with no deductible
Tier 4 20% up to $100 20% up to $100
New 2023 Team Member Cost/Week
TM only $42.00 $21.00 $17.50
TM + Child(ren) $138.50 $76.50 $62.75
TM + Spouse $153.50 $86.50 $75.50
TM + Family $190.00 $97.00 $80.00

Notes: If your spouse has coverage available through his/her employer but chooses not to enroll in that plan as their primary insurance, you will be
subject to an additional $60 per week surcharge.
These rates do not reflect any wellness program credits or surcharges

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