Page 6 - AMT Gordian TEXAS EE Guide 01-2020

BENEFITS

Medical Insurance

United Healthcare United Healthcare
Plan Name PPO Balanced AKLY PPO HSA BS6W
Network Name Select Plus Non-Network Select Plus Non-Network
Health Benefits
Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $750 $1,500 $2,800 $4,700
- Family $1,500 $3,000 $5,600 $9,400
Out-of-Pocket Maximum
- Individual $4,700 $9,500 $4,700 $9,400
- Family $9,500 $19,000 $9,400 $18,800
Co-Insurance (Plan Pays) 80% 60% 80% 60%
Office Visit Copay
- Preventive Care No Charge Not Covered No Charge Not Covered
- Primary Care Physician $25 Copay Ded, 40% Ded, 20% Ded, 40%
- Specialist Office Visit $25 Copay Ded, 40% Ded, 20% Ded, 40%
- Urgent Care $25 Copay Ded, 40% Ded, 20% Ded, 40%
- Virtual Visits $25 Copay N/A Ded, 20% N/A
Hospitalization
- Inpatient $100 Copay/ Ded, $100 Copay/Ded, Ded, 20% Ded, 40%
20% 40% Ded, 20% Ded, 40%
- Outpatient Surgery Ded, 20% Ded, 40%
Lab and X-Ray
- Diagnostic No Charge Ded, 40% Ded, 20% Ded, 40%
- Complex Ded, 20% Ded, 40% Ded, 20% Ded, 40%
Emergency Services $100 Copay + Ded, 20% Ded, 20%
Chiropractic $25 Copay Ded, 40% Ded, 20% Ded, 40%
24 Visits/Year 24 Visits/Year
Pharmacy Benefits

Pharmacy Deductible
- Individual $0 $0 Plan Deductible Applies
- Family $0 $0 Plan Deductible Applies
Retail Pharmacy
- Tier 1 $10 Copay $10 Copay $10 Copay $10 Copay
- Tier 2 $30 Copay $30 Copay $35 Copay $35 Copay
- Tier 3 $50 Copay $50 Copay $60 Copay $60 Copay
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1 $25 Copay Not Covered $25 Copay Not Covered
- Tier 2 $75 Copay $87.50 Copay
- Tier 3 $125 Copay $150 Copay
- Supply Limit 90 Days 90 Days
Specialty N/A N/A N/A N/A
- Supply Limit

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