Page 9 - Dragados 2022 Benefits Guide

Medical Plans
Administered by UnitedHealthcare
Medical Plan Provisions
Health Savings Account Offered Health Savings Account Funding
Calendar Year Deductible
Calendar Year Out-of-Pocket Maximum (includes the deductible)
Coinsurance (Plan Pays)
Office Visits
Hospitalization (Precertification required)
Emergency Room
Prescription Drugs
Pharmacy Deductible
Network Retail Pharmacy— Generic (up to 30-day supply)
Network Retail Pharmacy— Preferred Brand
(up to 0-day supply)
Network Retail Pharmacy— Non-Preferred Brand
(up to 30-day supply)
Mail Order (Home Delivery)— Generic (up to 90-day supply)
Mail Order (Home Delivery)— Preferred Brand
(up to 90-day supply)
Mail Order (Home Delivery)— Non-Preferred Brand
(up to 90-day supply)
Specialty Pharmacy Management
Step Therapy and Mandatory Generic Programs
In-Network
Out-of-Network**
In-Network
Out-of-Network
In-Network
Out-of-Network
EPO PLAN
HSA PLAN
OAP PLAN
NO
YES
NO
N/A
$600 single (pro-rated) $1,200 family (pro-rated)
N/A
$1,250 single $2,500 family
N/A
$1,750 single $3,500 family
$4,000 single $8,000 family
$750 single $1,500 family
$2,000 single $4,000 family
$4,250 single $8,500 family
N/A
$3,500 single $6,850 family
$7,000 single $14,000 family
$3,000 single $6,000 family
$7,000 single $14,000 family
80% after deductible
N/A
90% after deductible
70% after deductible
100% after deductible
70% after deductible
PCP: $30 copay Specialist: $50 copay
N/A
90% after deductible
70% after deductible
PCP: $30 copay Specialist: $50 copay
70% after deductible
80% after deductible
N/A
90% after deductible
70% after deductible
$500 copay
70% after deductible
$100 copay (waived if admitted)
90% after deductible
$250 copay (waived if admitted)
$100 single / $200 family
Included in medical deductible
$100 single / $200 family
$15 copay
$15 copay
$15 copay
$35 copay
$35 copay
$35 copay
$75 copay
$75 copay
$75 copay
$37.50 copay
$37.50 copay
$37.50 copay
$87.50 copay
$87.50 copay
$87.50 copay
$187.50 copay
$187.50 copay
$187.50 copay
Included
Included
Included
Included
Included
Included
Please refer to your UnitedHealthcare benefit summary for further details on plan coverage provisions. **Precertification requirements apply (see page 10 for more information)
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