Page 6 - Petroleum Mktg EE Guide 12-19

BENEFITS

Medical Insurance

United Healthcare United Healthcare United Healthcare United Healthcare
HMO 20-30/20% Advantage HMO Focus HMO Alliance HMO
Plan Name 20-30/20% 15-30/750A 25-40/30%
Signature Value Signature Value Signature Value Signature Value
Network Name HMO Advantage HMO Focus HMO Alliance HMO
Health Benefits
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual $0 $0 $0 $1,500
- Family $0 $0 $0 $3,000
Out-of-Pocket Maximum
- Individual $3,500 $3,500 $2,500 $5,000
- Family $7,000 $7,000 $5,000 $10,000
Co-Insurance (Plan Pays) 80% 80% 100% 70%
Office Visit Copay
- Preventive Care No Charge No Charge No Charge No Charge
- Primary Care Physician $20 Copay $20 Copay $15 Copay $25 Copay
- Specialist Office Visit $30 Copay $30 Copay $30 Copay $40 Copay
- Urgent Care $20 Copay $20 Copay $15 Copay $25 Copay
- Virtual Visits $20 Copay $20 Copay $15 Copay $25 Copay
Hospitalization
- Inpatient 20% 20% $750 Copay Deductible, 30%
- Outpatient 20% 20% $200 Copay Deductible, 30%

Lab and X-Ray
- Diagnostic No Charge No Charge No Charge $25 Copay
- Complex $50-$100 Copay $50-$100 Copay $50-$100 Copay $50-$100 Copay
Emergency Services $200 Copay $200 Copay $225 Copay $225 Copay
Chiropractic Not Covered Not Covered Not Covered Not Covered
Pharmacy Benefits

Pharmacy Deductible
- Individual $0 $0 $0 $0
- Family $0 $0 $0 $0
Retail Pharmacy
- Tier 1 $15 Copay $15 Copay $10 Copay $10 Copay
- Tier 2 $30 Copay $30 Copay $25 Copay $25 Copay
- Tier 3 $50 Copay $50 Copay $50 Copay $50 Copay
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1 $30 Copay $30 Copay $20 Copay $20 Copay
- Tier 2 $60 Copay $60 Copay $50 Copay $50 Copay
- Tier 3 $100 Copay $100 Copay $100 Copay $100 Copay
- Supply Limit 90 Days 90 Days 90 Days 90 Days

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