Page 14 - ABM 2021 Benefits Guide SVC 30+

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 plan will team member toward the cost.

UnitedHealthcare In-Network Bronze Out-of-Network
Calendar Year Deductible
Individual $5,000 Not covered
Family $10,000 Not covered
Out-of-Pocket Maximum
Individual $6,600 Not covered
Family $13,200 Not covered
Coinsurance 40% team member/60% plan Not covered
Physician Oice Visits
Primary Care 40% after deductible Not covered
Specialist 40% after deductible Not covered
Virtual Visits 40% after deductible No coverage
Urgent Care 40% after deductible Not covered
Wellness/Preventive No charge Not covered
Physician Oice Visits—Tier 1 Premium Care Physician
Primary Care 30% after deductible Not covered
Specialist 30% after deductible Not covered
Virtual Visits $25 copay Not covered
Lab Services
Physician Oice 40% after deductible Not covered
X-Ray/Radiology Services
Physician Oice 40% after deductible Not covered
Physician Oice—Premium No charge Not covered
Hospital Services
Inpatient 40% after deductible Not covered
Outpatient 40% after deductible Not covered
Outpatient Professional Fees—Surgical/Medical 40% after deductible Not covered
Outpatient Professional Fees—Surgical/Medical—Premium 30% after deductible Not covered
Emergency Room 40% after deductible Not covered
Mental Health
Inpatient 40% after deductible Not covered
Outpatient 40% after deductible Not covered
Outpatient—Premium 30% after deductible Not covered
Substance Abuse
Inpatient 40% after deductible Not covered
Outpatient 40% after deductible Not covered
Outpatient—Premium 30% after deductible Not covered
Prescription Drugs
Retail—Supply Limit 31-Day Supply
Tier 1 20% after deductible Not covered
Tier 2 40% after deductible Not covered
Tier 3 50% after deductible Not covered
Tier 4—Premium 50% after deductible
Mail Order—Supply Limit 90-Day Supply
Tier 1 20% after deductible Not covered
Tier 2 40% after deductible Not covered
Tier 3 50% after deductible Not covered
Tier 4—Premium 50% after deductible

14 2021 Benefits Enrollment