Page 7 - 61st Street Service Corporation | 2022 Benefits

Medical Plan
Administered by UnitedHealthcare
61st Street Service Corporation offers employees
and their families an HRA medical plan through UnitedHealthcare. Please review the benefit chart. DEPENDENT ELIGIBILITY: Eligible dependents include your spouse and dependent children until the child reaches age 26. Benefits discontinue at the end of the year in which the child turns 26.
Summary of HRA Medical Plan Benefits* & Costs
In-Network
Out-Of-Network
UnitedHealthcare
Choice Plus
(844) 637–7501 myuhc.com
Prescription Drug Plan
Express Scripts
(844) 424-8878 express-scripts.com/rx
20%
$2,500 / $4,500
40%
$7,000 / $14,000
Adult: Not covered Children: 40% after deductible
40% after deductible
40% after deductible
20% after deductible
40% after deductible
40% after deductible
40% after deductible
40% after deductible
Not covered
Calendar Year Deductible (Individual/Family)
Health Reimbursement Account
(Employer Funding)
Member Coinsurance
Out-of-Pocket Maximum**** (Individual/Family)
Preventive Care
Office Visits
Hospital Services (Inpatient & Outpatient**)
Emergency Room
Urgent Care
Lab & routine X-ray (Outpatient)
Maternity Care** (Prenatal and Post-Natal Care, Hospital Services for Mother and Child
Mental Health/Substance Abuse
Prescription Drugs*** (Up to a 30-day supply)
$1,500 / $3,000
$500
$4,000 / $8,000
Employee Only / $750 Employee + 1 / $1,200 Employee + 2 or more
Your preventive care visits are covered at
Covered 100%
20% after deductible
20% after deductible
20% after deductible
20% after deductible
100%, deductible does not apply
20% after deductible
20% after deductible
Up to $15 Generic
$35 Preferred Brand Name
$75 Non-Preferred Brand Name
100%
Benefits of Staying In-network
Our medical, dental and vision programs offer both in-network and out-of-network benefits to employees. However, to take advantage of carrier discounts and to save money, make sure to utilize in-network providers. When employees go out-of-network, they can be balance billed for amounts over and above what insurance will pay. To find in-network providers, search carrier websites or call them at the numbers indicated on their respective pages in this guide.
** These services require precertification through UnitedHealthcare.
*** Prescription medications ordered through the Mail Order Drug Program are subject to 2 1⁄2 applicable retail pharmacy copays.
****Copays, deductible & coinsurance CAP per Healthcare Reform guideline.
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