Page 10 - ABM 2021 Benefit Guide AMPCO

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 Gold Out-of-Network
Calendar Year Deductible
Individual $1,750 $3,000
Family $3,500 $6,000
Out-of-Pocket Maximum
Individual $5,000 med/$2,000 Rx $15,000 med/N/A Rx
Family $10,000 med/$4,000 Rx $30,000 med/
N/A Rx
Coinsurance 25% team member/75% plan 50% team member/
50% plan
Physician Oice Visits
Primary Care $25 copay 50% after deductible
Specialist $45 copay 50% after deductible
Virtual Visits $25 copay No coverage
Urgent Care $25 copay 50% after deductible
Wellness/Preventive No charge 50% after deductible
Physician Oice Visits—Tier 1 Premium Care Physician
Primary Care $15 copay 50% after deductible
Specialist $35 copay 50% after deductible
Lab Services
Physician Oice No charge 50% after deductible
X-Ray/Radiology Services
Physician Oice No charge 50% after deductible
Hospital Services
Inpatient Min $250/max $500 + 25% after 50% after deductible
deductible
Outpatient $200, 25% after deductible $500 copay + 50% after deductible
Outpatient Professional Fees— 25% after deductible 50% after deductible
Surgical/Medical
Outpatient Professional Fees— 15% after deductible 50% after deductible
Surgical/Medical—Tier 1 Premium Care
Physician
Emergency Room $200 copay, 25% after deductible $200 copay, 25% after deductible

10 2021 Benefits Enrollment