Page 7 - PSA 2020-21 New Hire Guide
P. 7
Protection Strategies Incorporated
Medical Plan Details
United Healthcare
Core Buy-Up
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $2,800 $2,800 $750 $2,500
Family $5,600 $5,600 $1,500 $5,000
Out-of-Pocket Maximum (includes deductible)
Individual $5,600 $5,600 $4,000 $5,000
Family $11,200 $11,200 $8,000 $10,000
Physician Oice Visits
Preventive Care Covered at 100% Covered at 100%
Primary Care Visit 100% after deductible 70% after deductible $25 copay 50% after deductible
Specialist Visit 100% after deductible 70% after deductible $50 copay 50% after deductible
Urgent Care 100% after deductible 70% after deductible $50 copay 50% after deductible
Hospital Services
Inpatient 100% after deductible 70% after deductible 80% after deductible 50% after deductible
Outpatient 100% after deductible 70% after deductible 80% after deductible 50% after deductible
Emergency Room 100% after deductible 70% after deductible $350 copay $350 copay
Prescription Drugs
Please note: for the HSA qualiied plans, all prescription drug expenses are subject to the medical deductible. Once you meet your
deductible, copays or coinsurance will apply.
Retail—Supply Limit
X Tier 1 $10 copay Not covered $10 copay Not covered
X Tier 2 $35 copay Not covered $75 copay Not covered
X Tier 3 $75 copay Not covered $150 copay Not covered
X Tier 4 $150 copay Not covered $300 copay Not covered
Mail Order—Supply Limit
X Tier 1 $25 copay Not covered $25 copay Not covered
X Tier 2 $87.50 copay Not covered $187.50 copay Not covered
X Tier 3 $187.50 copay Not covered $375 copay Not covered
X Tier 4 $375 copay Not covered $750 copay Not covered
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In
the event there is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD
will prevail.
Virtual Visits
When you’re sick and need care quick, a virtual visit is a
convenient way to start feeling better faster.
With a virtual visit, you can see and talk to a doctor via
mobile device or computer—24/7, no appointment needed.
The doctor can give you a diagnosis and prescription, if
needed. With a United Healthcare plan, your cost is $50
or less.
To get started with a virtual visit, go to
uhc.com/virtualvisits.
7
Medical Plan Details
United Healthcare
Core Buy-Up
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $2,800 $2,800 $750 $2,500
Family $5,600 $5,600 $1,500 $5,000
Out-of-Pocket Maximum (includes deductible)
Individual $5,600 $5,600 $4,000 $5,000
Family $11,200 $11,200 $8,000 $10,000
Physician Oice Visits
Preventive Care Covered at 100% Covered at 100%
Primary Care Visit 100% after deductible 70% after deductible $25 copay 50% after deductible
Specialist Visit 100% after deductible 70% after deductible $50 copay 50% after deductible
Urgent Care 100% after deductible 70% after deductible $50 copay 50% after deductible
Hospital Services
Inpatient 100% after deductible 70% after deductible 80% after deductible 50% after deductible
Outpatient 100% after deductible 70% after deductible 80% after deductible 50% after deductible
Emergency Room 100% after deductible 70% after deductible $350 copay $350 copay
Prescription Drugs
Please note: for the HSA qualiied plans, all prescription drug expenses are subject to the medical deductible. Once you meet your
deductible, copays or coinsurance will apply.
Retail—Supply Limit
X Tier 1 $10 copay Not covered $10 copay Not covered
X Tier 2 $35 copay Not covered $75 copay Not covered
X Tier 3 $75 copay Not covered $150 copay Not covered
X Tier 4 $150 copay Not covered $300 copay Not covered
Mail Order—Supply Limit
X Tier 1 $25 copay Not covered $25 copay Not covered
X Tier 2 $87.50 copay Not covered $187.50 copay Not covered
X Tier 3 $187.50 copay Not covered $375 copay Not covered
X Tier 4 $375 copay Not covered $750 copay Not covered
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In
the event there is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD
will prevail.
Virtual Visits
When you’re sick and need care quick, a virtual visit is a
convenient way to start feeling better faster.
With a virtual visit, you can see and talk to a doctor via
mobile device or computer—24/7, no appointment needed.
The doctor can give you a diagnosis and prescription, if
needed. With a United Healthcare plan, your cost is $50
or less.
To get started with a virtual visit, go to
uhc.com/virtualvisits.
7
