Page 7 - Roll-A-Shade Ben Guide 6-2020

Benefits

Medical Insurance

United Healthcare United Healthcare
Silver $1,500 PPO Gold $1,000 PPO
Network Name Select Plus Non-Network Select Plus Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $1,500 $3,000 $1,000 $2,000
- Family $3,000 $6,000 $2,000 $4,000
Co-Insurance (You Pay) 40% 50% 20% 50%

Office Visit Copay
- Primary Care Physician $50 Copay Deductible, 50% $25 Copay Deductible, 50%
- Specialist Office Visit $80 Copay Deductible, 50% $50 Copay Deductible, 50%
- Virtual Visits $5 Copay Not Covered $5 Copay Not Covered

Out-of-Pocket Maximum Deductible Applies Deductible Applies Deductible Applies Deductible Applies
- Individual $8,150 $16,300 $6,500 $13,000
- Family $16,300 $32,600 $13,000 $26,000
Hospitalization
- Inpatient $250 Copay, Ded, 40% $250 Copay, Ded, 50% $250 Copay, Ded, 20% $250 Copay, Ded, 50%
- Outpatient $250 Copay, Ded, 40% $250 Copay, Ded, 50% $250 Copay, Ded, 20% $250 Copay, Ded, 50%

Lab and X-Ray Ded, 40% ($250 Copay $250 Copay, Ded, 50% $250 Copay, Ded, 20% $250 Copay, Ded, 50%
Emergency Services $300, Ded, 40% $250, Ded, 20%
Urgent Care $80 Copay Deductible, 50% $75 Copay Deductible, 50%

Preventive Care No Charge Not Covered No Charge Not Covered
Chiropractic $50 Copay Deductible, 50% $25 Copay Deductible, 50%

(Limit 24 visits/year) (Limit 24 visits/year)
Pharmacy Benefits
Pharmacy Deductible
- Individual $300 $250
- Family $600 $500

Retail Pharmacy
- Tier 1 (Deductible Waived) $20 Copay $20 Copay $15 Copay $15 Copay
- Tier 2 $50 Copay $50 Copay $40 Copay $40 Copay
- Tier 3 $100 Copay $100 Copay $80 Copay $80 Copay
- Tier 4 25% ($250 Max) 25% ($250 Max) 25% ($250 Max) 25% ($250 Max)
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1 (Deductible Waived) $50 Copay Not Covered $37.50 Copay Not Covered
- Tier 2 $125 Copay Not Covered $100 Copay Not Covered
- Tier 3 $250 Copay Not Covered $200 Copay Not Covered
- Tier 4 25% ($625 Max) Not Covered 25% ($625 Max) Not Covered
- Supply Limit 90 Days N/A 90 Days N/A

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