Page 5 - Benefit Guide Stamford Residence and Rehab

Medical Options:

United Healthcare (UHC)

Effective 1-1-2020 ance Premier Premier Premier We offer our full-time employees and their eligible
ProForm
Bi-Weekly Pay Period AXKY-IU BCZ2-IU BCZY-IU BCZS-IU
dependents coverage. Children can join or remain
Employee Only $ 80.00 $100.00 $120.00 $160.00 on a parent’s medical plan until age 26. When a
Employee + Spouse $275.00 $400.00 $500.00 $553.85 child turns 26, they will lose medical coverage on the
Employee + Child(ren) $225.00 $300.00 $400.00 $461.54 last day of their birth month.
Employee + Family $406.25 $700.00 $800.00 $923.08

ProFormance AXKY Premier BCZ2 Premier BCZY Premier BCZS
Brief Member $5,000 Deductible $3,000 Deductible $2,000 Deductible $3,000 Deductible
In-Network Summary IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY IN-NETWORK ONLY
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COVID-19 Testing & Treat- Covered 100% Covered 100% vered 100% red 100%
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ment (during COVID period) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
Network CHOICE CHOICE CHOICE CHOICE
(CYD) Calendar Year De- Individual: $5,000 Individual: $3,000 Individual: $2,000 Individual: $3,000
ductible (Jan .1st to Dec. Family: $10,000 Family: $6,000 Family: $4,000 Family: $6,000
31st)
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Coinsurance Carrier: 80% arrier: 80% Carrier: 80% rrier: 100%
(After CYD) Member: 20% Member: 20% Member: 20% Member: 0%
Annual (OOP) Out of Pock- Individual: $7,150 Individual: $6,000 Individual: $6,000 Individual: $4,500
et Maximum Family: $14,300 Family: $12,000 Family: $12,000 Family: $9,000
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Primary Care Physician Under Age 19: $0 Copay Under Age 19: $0 Copay Age 19: $0 Copay e 19: $0 Copay
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(PCP) Age 19 & Over: $15 Copay Age 19 & Over: $30 Copay Age 19 & Over: $30 Copay Age 19 & Over: $30 Copay
UHC Network Providers UHC Network Providers UHC Network Providers UHC Network Providers
Specialist Physicians and $50 Copay -Designated $30 Copay -Designated $30 Copay -Designated $30 Copay -Designated
Non PCP Providers
$100 Copay -Standard $60 Copay -Standard $60 Copay -Standard $60 Copay -Standard
Dr. Consultation Virtual
Visits (Telehealth) see page $0 Copay $0 Copay $0 Copay $0 Copay
6&7
Basic: Lab, X-Rays / Diag- Basic: 20% after CYD Basic: Paid 100% Basic: Paid 100% Basic: Paid 100%
nostic Major: Diagnostic & Major: 20% after CYD Major: 20% after CYD Major: 20% after CYD Major: Paid 100% after CYD
Imaging
Annual Preventive Care Covered 100% Covered 100% vered 100% red 100%
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(Certain Rx are covered (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
too) See page 4
$25 copay (Dr. Services Only)
Urgent Care $75 Copay $75 Copay $75 Copay
(CYD/20% apply to other services)
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20% after $250 Copay 0% after $250 Copay $300 Copay
Emergency Room $300 Copay, after CYD and 20%
CYD does not apply CYD does not apply CYD does not apply
Hospitalization: 20% after CYD 20% after CYD 20% after CYD Paid 100% after CYD
(In / Outpatient)
Prescription Drugs - 31 Day RX Plan IU RX Plan IU RX Plan IU RX Plan IU

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Supply Retail Tier 1 $15 Copay ier 1 $15 Copay 1 $15 Copay $15 Copay
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90 Day Supply Mail Order Tier 2 $40 Copay ier 2 $40 Copay 2 $40 Copay $40 Copay
at 2.5 Times Retail Tier 3 $75 Copay Tier 3 $75 Copay Tier 3 $75 Copay Tier 3 $75 Copay
NOTE: This is only a brief overview. Please see Benefit Summary and SBC for more details. Please Register and use UHC Member www.myuhc.com or
Customer Service Toll Free 866-633-2446
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