Page 14 - ABM 2021 Benefit Guide MDV
P. 14
Silver (CDHP with HSA)* Gold Platinum
United Healthcare
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Mental Health
Inpatient 20% after deductible 50% after deductible $250 copay per day + 50% after deductible $250 copay per day + 50% after deductible
25% after deductible 20% after deductible
Outpatient 20% after deductible 50% after deductible $25 copay 50% after deductible $25 copay 50% after deductible
Outpatient—Tier 1 Premium Care $15 copay 50% after deductible $15 copay 50% after deductible 10% after deductible 50% after deductible
Physician
Substance Abuse
Inpatient 20% after deductible 50% after deductible $250 copay per day, 50% after deductible $250 copay per day, 20% after deductible 50% after deductible
25% after deductible
Outpatient 20% after deductible 50% after deductible $25 copay 50% after deductible $25 copay 50% after deductible
Outpatient—Tier 1 Premium Care $15 copay 50% after deductible $15 copay 50% after deductible 10% after deductible 50% after deductible
Physician
Prescription Drugs
Retail—supply limit 31-day supply 31-day supply 31-day supply
Tier 1 $10 copay, after deductible Not covered $15 copay Not covered $15 copay Not covered
Tier 2 $35 copay, after deductible Not covered 40%—$45 min/$90 max Not covered 40%—$45 min/$90 max Not covered
Tier 3 $60 copay, after deductible Not covered 50%—$70 min/$140 max Not covered 50%—$70 min/$140 max Not covered
Tier 4 Deductible, then $200 Not covered 10%—$150 max Not covered 10%—$150 max Not covered
copay + 20%
Mail Order—supply limit 90-day supply 90-day supply 90-day supply
Tier 1 $20 copay, after deductible N/A $37.50 copay N/A $37.50 copay N/A
Tier 2 $70 copay, after deductible N/A 40%-$112.50 min/$225 max N/A 40%-$112.50 min/$225 max N/A
Tier 3 $120 copay, after deductible N/A 50%-$175 min/$350 max N/A 50%-$175 min/$350 max N/A
Tier 4 Deductible, then $200 N/A 10%-$150 max N/A 10%-$150 max N/A
copay + 20%
* Refer to the page titled “Health Savings Account” for more information.
14 2021 Benefits Enrollment
United Healthcare
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Mental Health
Inpatient 20% after deductible 50% after deductible $250 copay per day + 50% after deductible $250 copay per day + 50% after deductible
25% after deductible 20% after deductible
Outpatient 20% after deductible 50% after deductible $25 copay 50% after deductible $25 copay 50% after deductible
Outpatient—Tier 1 Premium Care $15 copay 50% after deductible $15 copay 50% after deductible 10% after deductible 50% after deductible
Physician
Substance Abuse
Inpatient 20% after deductible 50% after deductible $250 copay per day, 50% after deductible $250 copay per day, 20% after deductible 50% after deductible
25% after deductible
Outpatient 20% after deductible 50% after deductible $25 copay 50% after deductible $25 copay 50% after deductible
Outpatient—Tier 1 Premium Care $15 copay 50% after deductible $15 copay 50% after deductible 10% after deductible 50% after deductible
Physician
Prescription Drugs
Retail—supply limit 31-day supply 31-day supply 31-day supply
Tier 1 $10 copay, after deductible Not covered $15 copay Not covered $15 copay Not covered
Tier 2 $35 copay, after deductible Not covered 40%—$45 min/$90 max Not covered 40%—$45 min/$90 max Not covered
Tier 3 $60 copay, after deductible Not covered 50%—$70 min/$140 max Not covered 50%—$70 min/$140 max Not covered
Tier 4 Deductible, then $200 Not covered 10%—$150 max Not covered 10%—$150 max Not covered
copay + 20%
Mail Order—supply limit 90-day supply 90-day supply 90-day supply
Tier 1 $20 copay, after deductible N/A $37.50 copay N/A $37.50 copay N/A
Tier 2 $70 copay, after deductible N/A 40%-$112.50 min/$225 max N/A 40%-$112.50 min/$225 max N/A
Tier 3 $120 copay, after deductible N/A 50%-$175 min/$350 max N/A 50%-$175 min/$350 max N/A
Tier 4 Deductible, then $200 N/A 10%-$150 max N/A 10%-$150 max N/A
copay + 20%
* Refer to the page titled “Health Savings Account” for more information.
14 2021 Benefits Enrollment
