Page 5 - Benefit Guide Austin Healthcare & Rehabilitation Final 101420

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 & Treatment Covered 100% Covered 100% overed 100% ered 100%
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(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 Deductible Individual: $5,000 Individual: $3,000 Individual: $2,000 Individual: $3,000
(Jan .1st to Dec. 31st) Family: $10,000 Family: $6,000 Family: $4,000 Family: $6,000
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Coinsurance Carrier: 80% arrier: 80% Carrier: 80% arrier: 100%
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(After CYD) Member: 20% Member: 20% Member: 20% Member: 0%
Annual (OOP) Out of Pocket Individual: $7,150 Individual: $6,000 Individual: $6,000 Individual: $4,500
Maximum Family: $14,300 Family: $12,000 Family: $12,000 Family: $9,000

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Under Age 19: $0 Copay Under Age 19: $0 Copay Age 19: $0 Copay ge 19: $0 Copay
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Primary Care Physician (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 Non $50 Copay -Designated $30 Copay -Designated $30 Copay -Designated $30 Copay -Designated
PCP Providers
$100 Copay -Standard $60 Copay -Standard $60 Copay -Standard $60 Copay -Standard
Dr. Consultation Virtual Visits $0 Copay $0 Copay $0 Copay $0 Copay
(Telehealth) see page 6&7
Basic: Lab, X-Rays / Diagnostic Basic: 20% after CYD Basic: Paid 100% Basic: Paid 100% Basic: Paid 100%
Major: Diagnostic & Imaging Major: 20% after CYD Major: 20% after CYD Major: 20% after CYD Major: Paid 100% after CYD
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Annual Preventive Care (Certain Covered 100% Covered 100% overed 100% ered 100%
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Rx are covered too) See page 4 (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays) (No CYD, Co-Ins. Copays)
$25 copay (Dr. Services Only)
Urgent Care $75 Copay $75 Copay $75 Copay
(CYD/20% apply to other services)
20% after $250 Copay 20% 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 Tier 1 $15 Copay r 1 $15 Copay 1 $15 Copay
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90 Day Supply Mail Order at 2.5 Tier 2 $40 Copay ier 2 $40 Copay r 2 $40 Copay $40 Copay
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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