Page 12 - ABM 2021 Benefit Guide MGT

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 log in to myuhc.com . The coinsurance percentage shown in the chart below represents the amount
®
the team member will pay toward the cost.
Silver (CDHP with HSA)* Gold Platinum
United Healthcare
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $2,800 $6,000 $1,750 $3,000 $725 $2,400
Family $5,600 $12,000 $3,500 $6,000 $1,450 $4,800
Out-of-Pocket Maximum
Individual $5,000 $10,000 $5,000 med/$2,000 Rx $15,000 med/Rx N/A $3,000 med/$2,000 Rx $10,000 med/Rx N/A
Family $10,000 $20,000 $10,000 med/$4,000 Rx $30,000 med/Rx N/A $6,000 med/$4,000 Rx $20,000 med/Rx N/A
Coinsurance 20% team member/80% plan 50% 25% team member/75% plan 50% team member/50% plan 20% team member/80% plan 50% team member/50% plan
Physician Oice Visits
Primary Care 20% after deductible 50% after deductible $25 copay 50% after deductible $25 copay 50% after deductible
Specialist 20% after deductible 50% after deductible $45 copay 50% after deductible $45 copay 50% after deductible
Virtual Visits 20% after deductible No coverage $25 copay No coverage $25 copay No coverage
Urgent Care 20% after deductible 50% after deductible $25 copay 50% after deductible $25 copay 50% after deductible
Wellness/Preventive No charge 50% after deductible No charge 50% after deductible No charge 50% after deductible
Physician Oice Visits—Tier 1 Premium Care Physician
Primary Care 10% after deductible 50% after deductible $15 Copay 50% after deductible $15 Copay 50% after deductible
Specialist 10% after deductible 50% after deductible $35 Copay 50% after deductible $35 Copay 50% after deductible
Lab Services
Physician Oice 20% after deductible 50% after deductible No charge 50% after deductible No charge 50% after deductible
X-Ray/Radiology Services
Physician Oice 20% after deductible 50% after deductible No charge 50% after deductible No charge 50% after deductible
Hospital Services
Inpatient 20% after deductible 50% after deductible Min $250/max $500 + 25% after 50% after deductible Min $250/max $500 + 20% after 50% after deductible
deductible deductible
Outpatient 20% after deductible 50% after deductible $200 + 25% after deductible $500 copay + 50% after $200 + 20% after deductible $500 copay + 50% after
deductible deductible
Outpatient Professional Fees—Surgical/ 20% after deductible 50% after deductible 25% after deductible 50% after deductible 20% after deductible 50% after deductible
Medical
Outpatient Professional Fees—Surgical/ 10% after deductible 50% after deductible 15% after deductible 50% after deductible 10% after deductible 50% after deductible
Medical—Tier 1 Premium Care Physician
Emergency Room 20% after deductible 20% after deductible $200 copay, 25% after deductible $200 copay, 25% after deductible $200 copay, $200 copay, 20% after deductible
20% after deductible

12 2021 Benefits Enrollment