Page 5 - Stamford Residence & Rehabilitation - Benefit Guide 3-1-2021
P. 5

Medical Options:


          United Healthcare (UHC)



                                   Navigate
              Effective 3/1/2021                            ProFormance      Premier     Premier     We  offer  our  full-time  employees  and  their  eligible
            Bi-Weekly Pay Period   AYZB-IU    AXKY-IU   BCZ2-IU   BCZS-IU
                                                                            dependents  coverage.  Children  can  join  or  remain
         Employee Only             $  72.41   $  94.52   $118.25   $179.89   on  a  parent’s  medical  plan  until  age  26.  When  a
         Employee + Spouse         $256.62   $310.14    $444.17   $601.99   child turns 26, they will lose medical coverage on the
         Employee + Child(ren)     $211.26   $251.28    $333.03   $497.54   last day of their birth month.
         Employee + Family         $380.97   $454.60    $760.77   $989.32

                                 Navigate HMO AYZB $5,000   ProFormance AXKY                   Premier BCZ2               Premier BCZS
               Brief Member                            $5,000 Deductible   $5,000 Deductible   $3,000 Deductible   $3,000 Deductible
             Network Summary        IN-NETWORK ONLY       IN-NETWORK ONLY      IN-NETWORK ONLY     IN-NETWORK ONLY
                                                                                                      o
                                                                                                       v
                                                                                                     C
                                                                                  C
          COVID-19 Testing & Vaccine   Covered 100%                                      Covered 100%                                      overed 100%                                      ered 100%
          COVID period)            (No CYD, Co-Ins. Copays)   (No CYD, Co-Ins. Copays)   (No CYD, Co-Ins. Copays)   (No CYD, Co-Ins. Copays)
          Network                   Navigate “TEXAS” Only      CHOICE               CHOICE             CHOICE
          (CYD) Calendar Year Deductible   Individual: $5,000   Individual: $5,000   Individual: $3,000   Individual: $3,000
          (Jan .1st to Dec. 31st)     Family: $10,000       Family: $10,000       Family: $6,000     Family: $6,000
                                                                                   a
                                                                                    r
                                                                                                      C
                                                             C
                                                                                  C
          Coinsurance                  Carrier: 100%                                            arrier: 80%                                            rier: 80%                                    arrier: 100%
          (After CYD)                  Member: 0%            Member: 20%          Member: 20%         Member: 0%
          Annual (OOP) Out of Pocket   Individual: $7,350   Individual: $7,150   Individual: $6,000    Individual: $4,500
          Maximum                     Family: $14,700       Family: $14,300      Family: $12,000     Family: $9,000
                                    Under Age 19: $0 Copay                  Under Age 19: $0 Copay                  Under Age 19: $0 Copay                            ge 19: $0 Copay
                                                                                                  U
                                                                                                     e
                                                                                                   n

                                                                                                      r
                                                                                                    d
                                                                                                      A
          Primary Care Physician (PCP)
                                   Age 19 & Over: $10 Copay   Age 19 & Over: $15 Copay   Age 19 & Over: $30 Copay   Age 19 & Over: $30 Copay
                                  $60 Copay (you must have a           UHC Network Providers    UHC Network Providers   UHC Network Providers
          Specialist Physicians and Non   referral from your PCP) Not needed for   $50 Copay -Designated    $30 Copay -Designated    $30 Copay -Designated
          PCP Providers          (OB/GYN’s)., Urgent Care, Behavioral health or
                                        use  disorder  clinicians.    $100 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:  $40 Copay CYD Waived   Basic:  20% after CYD    Basic:  Paid 100%    Basic:  Paid 100%
          Major: Diagnostic & Imaging   Major:  $500 Copay    Major:  20% after CYD    Major:  20% after CYD    Major: Paid 100% after CYD
                                                                                                       v
                                                                                                      o
                                                                                  C
                                                                                                     C
          Annual Preventive Care (Certain   Covered 100%                                      Covered 100%                                      overed 100%                                      ered 100%
          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)
                                                                   r
                                                                    v
                                                                 S
                                                                  e
                                                                    ic

                                                                       O
                                                                     e
                                                                      s
                                                           C

                                                            p
                                                            o
                                                        $
                                  $25 Copay (Dr. Services Only)                                                        nly)
                                                          5
                                                         2
                                                             a
                                                               D
                                                               (


                                                                 .
                                                                r
                                                              y
          Urgent Care                                                              $75 Copay          $75 Copay
                                  (CYD apply to other services)    (CYD/20% apply to other services)
                                                                                20% after $250 Copay                       $300 Copay
          Emergency Room            $500 Copay, after CYD   $300 Copay, after CYD and 20%
                                                                                CYD does not apply   CYD does not apply
          Hospitalization:                          Paid 100% 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
                                                                                                     ie
                                                                                                      r

                                                                                                     T
                                                                                 T
                                                                                  ie
          Supply Retail               Tier 1 $15 Copay                                   Tier 1 $15 Copay                                   r 1 $15 Copay                                   1 $15 Copay
                                                                                 T
                                                                                  ie

                                                            T
                                                                                                      r
                                                                                                     ie
                                                                                                     T
                                                                                                       2
          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
                                                              5
   1   2   3   4   5   6   7   8   9   10