Page 15 - ABM 2021 Benefit Guide MGT
P. 15
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 + 25% after 50% after deductible $250 copay per day + 20% after 50% after deductible
deductible deductible
Outpatient 20% after deductible 50% after deductible $25 copay 50% after deductible $25 copay 50% after deductible
Outpatient—Tier 1 Premium Care Physician 10% after deductible 50% after deductible $15 copay 50% after deductible $15 copay 50% after deductible
Substance Abuse
Inpatient 20% after deductible 50% after deductible $250 copay per day, 25% after 50% after deductible $250 copay per day, 20% after 50% after deductible
deductible deductible
Outpatient 20% after deductible 50% after deductible $25 copay 50% after deductible $25 copay 50% after deductible
Outpatient—Tier 1 Premium Care Physician 10% after deductible 50% after deductible $15 copay 50% after deductible $15 copay 50% after deductible
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 copay + 20% Not covered 10%-$150 max Not covered 10%-$150 max Not covered
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/ N/A 40%-$112.50 min/ N/A
$225 max $225 max
Tier 3 $120 copay, after deductible N/A 50%-$175 min/ N/A 50%-$175 min/ N/A
$350 max $350 max
Tier 4 Deductible, then $200 copay + 20% N/A 10%-$150 max N/A 10%-$150 max N/A
* Refer to the page titled “Health Savings Account” for more information.
ABM 15
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 + 25% after 50% after deductible $250 copay per day + 20% after 50% after deductible
deductible deductible
Outpatient 20% after deductible 50% after deductible $25 copay 50% after deductible $25 copay 50% after deductible
Outpatient—Tier 1 Premium Care Physician 10% after deductible 50% after deductible $15 copay 50% after deductible $15 copay 50% after deductible
Substance Abuse
Inpatient 20% after deductible 50% after deductible $250 copay per day, 25% after 50% after deductible $250 copay per day, 20% after 50% after deductible
deductible deductible
Outpatient 20% after deductible 50% after deductible $25 copay 50% after deductible $25 copay 50% after deductible
Outpatient—Tier 1 Premium Care Physician 10% after deductible 50% after deductible $15 copay 50% after deductible $15 copay 50% after deductible
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 copay + 20% Not covered 10%-$150 max Not covered 10%-$150 max Not covered
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/ N/A 40%-$112.50 min/ N/A
$225 max $225 max
Tier 3 $120 copay, after deductible N/A 50%-$175 min/ N/A 50%-$175 min/ N/A
$350 max $350 max
Tier 4 Deductible, then $200 copay + 20% N/A 10%-$150 max N/A 10%-$150 max N/A
* Refer to the page titled “Health Savings Account” for more information.
ABM 15
