Page 4 - Adolph's Litho Services - Benefit guide - Effective 3-1-2020

Medical Options:

United Healthcare

2020 Rate Information—Per Pay Period

Employee Employer Dependent Information
Per Pay Period
Weekly Cost Monthly Cost
Adolph’s Litho Services offers employees the
Employee Only $ 0.00 $ 774.74 opportunity to cover their spouse and

Employee + Spouse $25.00 $1,441.15 dependent children. Children can join or
remain on a parent’s plan until age 26. They
Employee + Child(ren) $25.00 $1,441.15 will lose medical coverage on the last day of
Employee + Family $25.00 $2,215.89 their birth month.

EPO — In Network Benefits Only
Summary of BR-QR w/DV No Out Of Network Benefits with this Plan
$5,000 Deductible
Unless an EMERGENCY

Deductible– Calendar Year Deductible Individual: $5,000
(CYD) Family: $10,000

Coinsurance 100%

Individual: $7,000
Annual Out of Pocket Maximum
Family: $14,000

Office Visit - Primary Care Physician (PCP) Under Age 19: $0 Copay
No REFERRAL NEEDED Age 19 and Over: $30 Copay

Virtual Designated Network Providers $0 Copay
(Telehealth) See Page 6 For More Details
$30 Copay (Designated Network)
Office Visit - Specialist
$60 Copay (Network)
Preventive Care Covered at 100%

Labs / X-rays Covered at 100%
MRI’s / PT’s / CT’s, Etc. (No CYD) $400 Copay

Urgent Care $50 Copay

$350 Copay
Emergency Room Copay
Out of Network Emergency Room $350 Copay
Tier 1: $20 Copay
Prescription Drugs—31 Day Supply Retail Tier 2: $45 Copay
(90 Day Mail Order at 2.5 Times Retail Tier 3: : $80 Copay
Copay)
Specialty: $20 / $100 / $300

NOTE: This is only intended as a brief overview. Please see Benefit Summary or contact United Healthcare for more details.
Support Tools @ www.myuhc.com or Customer Service @ 866-633-2446
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