Page 11 - Skyline Windows | 2022 Benefits Guide

BRIEF SUMMARY OF UNITED HEALTHCARE MEDICAL PLAN BENEFITS
Benefit Highlights
Employer Paid HRA Funding
Deductible
Coinsurance
Out-of-Pocket Maximum
Maximum Reimbursable Charge
Adult Preventative Care
Primary Care Office Visit Copay
Specialty Care Office Visit Copay
Complex Imaging Hospital Outpatient Diagnostic X-Ray/Labs Hospital Inpatient Emergency Room Urgent Care
Lifetime Maximum
Pharmacy Copays (Retail Store)
Pharmacy Copays Mail Order
Choice Plus POS
(In and Out-of-Network Coverage)
N/A $1,000 Individual / $2,500 Family
20% of contracted rate after deductible $3,000 Individual / $6,000 Family
N/A No Charge $25 copay
$40 copay
20% of contracted rate after deductible 20% of contracted rate after deductible No Charge
20% of contracted rate after deductible
Choice EPO HRA
(In-Network Coverage Only)
$500 Individual / $1,000 Family $1,500 Individual / $3,000 Family 20% of contracted rate after deductible $5,000 individual / $10,000 family
N/A
No Charge
20% of contracted rate after deductible
20% of contracted rate after deductible
20% of contracted rate after deductible 20% of contracted rate after deductible 20% of contracted rate after deductible 20% of contracted rate after deductible 20% of contracted rate after deductible 20% of contracted rate after deductible Unlimited
$10 Generic (Tier 1)
$35 Brand (Tier 2)
$70 Non-preferred Brand (Tier 3)
$25 / $87.50 / $175
Please refer to full Summary of Benefits enclosure for fee schedule for more services.
$200 per visit copay (waived if admitted), then plan pays 100%
$50
Unlimited
$10 Generic (Tier 1)
$25 Brand (Tier 2)
$50 Non-preferred Brand (Tier 3)
$25 / $62.50 / $125
40% after deductible
N/A N/A
$2,000 Individual / $5,000 40% after deductible $6,000 Individual / $12,000
300% of Medicare 40% after deductible 40% after deductible
40% after deductible
40% after deductible 40% after deductible 40% after deductible 40% after deductible
Family Family
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