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MEDICAL PLAN CHANGE HIGHLIGHTS
Effective August 01, 2021

HMO 1 CURRENT PLAN RENEWAL PLAN
UnitedHealthcare UnitedHealthcare
Advantage Platinum 20-40/20% (BR-SX) Advantage Platinum 20-40/20% (CE-
NV)
Deductible In Net $0 $0
PC/Specialist In Net $20/$40 $20/$40
Co-Insurance In Net 20% 20%
OOP Limit In Net $3,500 $3,500
Inpatient Hospital In Net 20% 20%
Rx Generic In Net $15 $10
Rx Preferred In Net $35 $35
Rx Non-Preferred In Net $70 $70

HMO2 CURRENT PLAN RENEWAL PLAN
UnitedHealthcare UnitedHealthcare
Advantage Gold 30-60/1000d (BH-GZ) Advantage Gold 30-70/800d (CE-NW)
Deductible In Net $0 $0
PC/Specialist In Net $30/$60 $30/$70
Co-Insurance In Net 20% 20%
OOP Limit In Net $6,000 $7,000
Inpatient Hospital In Net $1,000/day; 4 days/admt $800/day; 5 days/admt
Rx Generic In Net $15 ded waived $10 ded waived
Rx Preferred In Net $40 after $100 $40 after $100
Rx Non-Preferred In Net $80 after $100 $85 after $100

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