Page 14 - ABM 2021 Benefit Guide EDU

Medical and Pharmacy Benefits

UnitedHealthcare. A highlight of the plans is shown in the following table. Please note all
medical copays apply toward the out-of-pocket maximum. To locate an in-network provider, call
855.226.3456 or login to myuhc.com . The coinsurance percentage shown in the chart below
®
represents the amount the team member will pay toward the cost.

United Healthcare In-Network Silver (CDHP with HSA)*
Out-of-Network
Calendar Year Deductible
Individual $2,800 $6,000
Family $5,600 $12,000
Out-of-Pocket Maximum
Individual $5,000 $10,000
Family $10,000 $20,000
Coinsurance 20% employee/80% plan 50%
Physician Oice Visits
Primary Care 20% after deductible 50% after deductible
Specialist 20% after deductible 50% after deductible
Virtual Visits 20% after deductible No coverage
Urgent Care 20% after deductible 50% after deductible
Wellness/Preventive No charge 50% after deductible
Physician Oice Visits—Tier 1 Premium Care Physician
Primary Care 10% after deductible 50% after deductible
Specialist 10% after deductible 50% after deductible
Lab Services
Physician Oice 20% after deductible 50% after deductible
X-Ray/Radiology Services
Physician Oice 20% after deductible 50% after deductible
Hospital Services
Inpatient 20% after deductible 50% after deductible
Outpatient 20% after deductible 50% after deductible
Outpatient Professional Fees—Surgical/Medical 20% after deductible 50% after deductible
Outpatient Professional Fees—Surgical/Medical—Tier 10% after deductible 50% after deductible
1 Premium Care Physician
Emergency Room 20% after deductible 20% after deductible
Mental Health
Inpatient 20% after deductible 50% after deductible
Outpatient 20% after deductible 50% after deductible
Outpatient—Tier 1 Premium Care Physician 10% after deductible 50% after deductible
Substance Abuse
Inpatient 20% after deductible 50% after deductible
Outpatient 20% after deductible 50% after deductible
Outpatient—Tier 1 Premium Care Physician 10% after deductible 50% after deductible
Prescription Drugs
Retail—Supply Limit 31-day supply
Tier 1 $10 copay, after deductible Not covered
Tier 2 $35 copay, after deductible Not covered
Tier 3 $60 copay, after deductible Not covered
Tier 4 Deductible, then $200 copay + 20% Not covered
Mail Order—Supply Limit 90-day supply
Tier 1 $20 copay, after deductible N/A
Tier 2 $70 copay, after deductible N/A
Tier 3 $120 copay, after deductible N/A
Tier 4 Deductible, then $200 copay + 20% N/A
* Refer to the page titled “Health Savings Account” for more information.

14 2021 Benefits Enrollment