Page 11 - ABM 2021 Benefit Guide AMPCO

United Healthcare In-Network Gold Out-of-Network
Mental Health
Inpatient $250 copay per day, 50% after deductible
25% after deductible

Outpatient $25 copay 50% after deductible
Outpatient—Tier 1 Premium Care $15 copay 50% after deductible
Physician
Substance Abuse
Inpatient $250 copay per day, 25% after deductible 50% after deductible
Outpatient $25 copay 50% after deductible
Outpatient—Tier 1 Premium Care $15 copay 50% after deductible
Physician
Prescription Drugs
Retail—Supply Limit 31-day supply
Tier 1 $15 copay Not covered
Tier 2 40%-$45 min/$90 max Not covered
Tier 3 50%-$70 min/$140 max Not covered
Tier 4 10% $150 max Not covered
Mail Order—Supply Limit 90-day supply
Tier 1 $37.50 copay N/A
Tier 2 40%-$112.50 min/$225 max N/A
Tier 3 50%-$175 min/$350 max N/A
Tier 4 10%-$150 max N/A

ABM 11