Page 5 - Lanter | 2022 Benefits Guide LAF
P. 5
Medical Plans
Gold PPO Plan HSA Plan Value PPO Plan
Calendar Year Deductible (embedded)
Individual $1,750 $3,000 $5,000
Family $3,500 $6,000 $10,000
Out-of-Pocket Maximum
Individual $6,500 $6,550 $7,150
Family $13,000 $13,100 $14,300
Hospital Services
Inpatient Ded then 80% Ded then 80% Ded then 80%
Outpatient Ded then 80% Ded then 80% Ded then 80%
Emergency Room $300 copay Ded then 80% $300 copay plus
Ded then 80%
Oice Visits
Preventive Care 100% covered 100% covered 100% covered
Virtual Visit $20 copay Ded then 80% $0 copay
Primary Care $35 copay Ded then 80% $15 copay
Specialist $70 copay Ded then 80% $75 copay
Chiropractic Care $35 copay Ded then 80% $15 copay
Urgent Care $100 copay Ded then 80% $25 copay
Prescription Drugs
Retail—30 Day Supply Preventive Rx 100%
covered**
Tier 1 $10 Ded then $10 $10
Tier 2 $50 Ded then $50 $65
Tier 3 $95 Ded then $95 $125
Tier 4 $250 Ded then $250 $250
Mail Order—Supply Limit of 90 Days
Tier 1 $25 Ded then $25 $25
Tier 2 $125 Ded then $125 $162.50
Tier 3 $237.50 Ded then $237.50 $312.50
Tier 4 $625 Ded then $625 $625
This is a summary of your in-network beneit coverage. Full coverage and out-of-network details are available in the policy or certiicate of coverage.
* If you purchase a Prescription Drug from a Non-Network Pharmacy, you are responsible for any diference between the Non-Network Pharmacy
charges and the amount UHC would have paid for the same drug at a Network Pharmacy.
** Preventive medications will be covered at 100% on the HSA Plan. They are not subject to a deductible or coinsurance. Contact Human Resources for
the Preventive Drug List.
Premium Per Pay Period
Tobacco Free Rates Tobacco User Rates
Gold PPO Plan HSA Plan Value PPO Plan Gold PPO Plan HSA Plan Value PPO Plan
Employee $63.72 $47.14 $32.56 $102.95 $86.37 $71.79
Employee and Spouse $190.85 $143.62 $115.49 $230.08 $182.85 $154.72
Employee and Child(ren) $133.92 $107.79 $81.78 $173.15 $147.02 $121.01
Family $287.10 $212.82 $180.48 $326.33 $252.06 $219.71
LANTER AIR FREIGHT 5
Gold PPO Plan HSA Plan Value PPO Plan
Calendar Year Deductible (embedded)
Individual $1,750 $3,000 $5,000
Family $3,500 $6,000 $10,000
Out-of-Pocket Maximum
Individual $6,500 $6,550 $7,150
Family $13,000 $13,100 $14,300
Hospital Services
Inpatient Ded then 80% Ded then 80% Ded then 80%
Outpatient Ded then 80% Ded then 80% Ded then 80%
Emergency Room $300 copay Ded then 80% $300 copay plus
Ded then 80%
Oice Visits
Preventive Care 100% covered 100% covered 100% covered
Virtual Visit $20 copay Ded then 80% $0 copay
Primary Care $35 copay Ded then 80% $15 copay
Specialist $70 copay Ded then 80% $75 copay
Chiropractic Care $35 copay Ded then 80% $15 copay
Urgent Care $100 copay Ded then 80% $25 copay
Prescription Drugs
Retail—30 Day Supply Preventive Rx 100%
covered**
Tier 1 $10 Ded then $10 $10
Tier 2 $50 Ded then $50 $65
Tier 3 $95 Ded then $95 $125
Tier 4 $250 Ded then $250 $250
Mail Order—Supply Limit of 90 Days
Tier 1 $25 Ded then $25 $25
Tier 2 $125 Ded then $125 $162.50
Tier 3 $237.50 Ded then $237.50 $312.50
Tier 4 $625 Ded then $625 $625
This is a summary of your in-network beneit coverage. Full coverage and out-of-network details are available in the policy or certiicate of coverage.
* If you purchase a Prescription Drug from a Non-Network Pharmacy, you are responsible for any diference between the Non-Network Pharmacy
charges and the amount UHC would have paid for the same drug at a Network Pharmacy.
** Preventive medications will be covered at 100% on the HSA Plan. They are not subject to a deductible or coinsurance. Contact Human Resources for
the Preventive Drug List.
Premium Per Pay Period
Tobacco Free Rates Tobacco User Rates
Gold PPO Plan HSA Plan Value PPO Plan Gold PPO Plan HSA Plan Value PPO Plan
Employee $63.72 $47.14 $32.56 $102.95 $86.37 $71.79
Employee and Spouse $190.85 $143.62 $115.49 $230.08 $182.85 $154.72
Employee and Child(ren) $133.92 $107.79 $81.78 $173.15 $147.02 $121.01
Family $287.10 $212.82 $180.48 $326.33 $252.06 $219.71
LANTER AIR FREIGHT 5
