Page 6 - Roll-A-Shade Ben Guide 6-2020

Benefits

Medical Insurance

United Healthcare United Healthcare
Gold Signature $500 HMO Platinum Signature HMO
Network Name United Healthcare Signature Value United Healthcare Signature Value
Health Benefits

Lifetime Maximum Benefit Unlimited Unlimited
Deductible (Annual)
- Individual $500 None
- Family $1,000 None

Co-Insurance (You Pay) 20% 20%
Office Visit Copay
- Primary Care Physician $30 Copay $20 Copay
- Specialist Office Visit $60 Copay $40 Copay
- Virtual Visits $5 Copay $5 Copay
Out-of-Pocket Maximum Deductible Applies N/A
- Individual $6,500 $3,500
- Family $13,000 $7,000
Hospitalization
- Inpatient Ded, 20% 20%
- Outpatient Facility Fee: Ded, 20% Facility Fee: 20%;
Surgeon Fee: 20% Surgeon Fee: No Charge
Lab and X-Ray $30 Copay ($200 Complex) $25 Copay ($200 Complex)
Emergency Services Ded, $500 20%

Urgent Care $30 Copay $20 Copay
Preventive Care No Charge No Charge
Chiropractic $15 Copay $15 Copay

(Limit 20 visits/year) (Limit 20 visits/year)
Pharmacy Benefits
Pharmacy Deductible
- Individual $250 None
- Family $500 None

Retail Pharmacy
- Tier 1 $15 Copay $15 Copay
- Tier 2 $40 Copay $35 Copay
- Tier 3 $80 Copay $70 Copay
- Tier 4 25% ($250 Max) 25% ($250 Max)
- Supply Limit 30 Days 30 Days

Mail Order Pharmacy
- Tier 1 $30 Copay $30 Copay
- Tier 2 $80 Copay $70 Copay
- Tier 3 $160 Copay $140 Copay
- Tier 4 25% ($500 Max) 25% ($500 Max)
- Supply Limit 90 Days 90 Days

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