Your employer offers medical insurance to protect the health of you and your family. It covers medical expenses such as visits to the doctor’s office, emergency care, and prescription drugs. It’s important to have a medical plan that meets your needs and the needs of your family.

Keep in mind that your out-of-pocket costs will be lower if you receive care from an in-network doctor and facility. To find an in-network doctor, please visit www.uhc.com.

Benefits	In-Network
Deductible (Indiv./Family)	$5,000/$10,000
Out-of-Pocket Max (Indiv./Family)	$6,350/$12,700
Member Coinsurance	20%
Physician Visits
Preventive Care	Fully Covered
Primary Care Visit	$30 Copay
Specialist Visit	Designated: $30 Copay In-Network: $60 Copay
Hospital Services
Physican Services	Deductible + 20%
Inpatient Hospitalization	Deductible + 20%
Outpatient Surgery	Deductible + 20%
Diagnostic Lab Tests & Imaging	Deductible + 20%
Urgent Care	$75 Copay
Emergency Room	$250 Copay + 20% Coinsurance
Retail Prescriptions
Tier 1 - Generic Drugs	$20 Copay
Tier 2 - Preferred Brand Drugs	$45 Copay
Tier 3 - Non-preferred Brand Drugs	$80 Copay
Tier 4 - Specialty Drugs	N/A

Per Pay Period Cost
Employee	$125.58
Employee + Spouse	$311.60
Employee + Child(ren)	$238.77
Employee + Family	$353.65

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Summary of Benefits

Your employer offers medical insurance to protect the health of you and your family. It covers medical expenses such as visits to the doctor’s office, emergency care, and prescription drugs. It’s important to have a medical plan that meets your needs and the needs of your family.

Keep in mind that your out-of-pocket costs will be lower if you receive care from an in-network doctor and facility. To find an in-network doctor, please visit www.uhc.com.

Benefits	In-Network
Deductible (Indiv./Family)	$3,500/$7,000
Out-of-Pocket Max (Indiv./Family)	$6,350/$12,700
Member Coinsurance	20%
Physician Visits
Preventive Care	Fully Covered
Primary Care Visit	Deductible + 20%
Specialist Visit	Deductible + 20%
Hospital Services
Physican Services	Deductible + 20%
Inpatient Hospitalization	Deductible + 20%
Outpatient Surgery	Deductible + 20%
Diagnostic Lab Tests & Imaging	Deductible + 20%
Urgent Care	Deductible + 20%
Emergency Room	Deductible + 20%
Retail Prescriptions
Tier 1 - Generic Drugs	$10 Copay
Tier 2 - Preferred Brand Drugs	$35 Copay
Tier 3 - Non-preferred Brand Drugs	$60 Copay
Tier 4 - Specialty Drugs	N/A

Per Pay Period Cost
Employee	$87.05
Employee + Spouse	$248.61
Employee + Child(ren)	$184.90
Employee + Family	$265.55

Downloads

Summary of Benefits

Your employer offers medical insurance to protect the health of you and your family. It covers medical expenses such as visits to the doctor’s office, emergency care, and prescription drugs. It’s important to have a medical plan that meets your needs and the needs of your family.

Keep in mind that your out-of-pocket costs will be lower if you receive care from an in-network doctor and facility. To find an in-network doctor, please visit www.uhc.com.

Benefits	In-Network
Deductible (Indiv./Family)	$1,500/$3,000
Out-of-Pocket Max (Indiv./Family)	$5,000/$10,000
Member Coinsurance	20%
Physician Visits
Preventive Care	Fully Covered
Primary Care Visit	$20 Copay
Specialist Visit	Designated: $20 Copay In-Network: $40 Copay
Hospital Services
Physican Services	Deductible + 20%
Inpatient Hospitalization	Deductible + 20%
Outpatient Surgery	Deductible + 20%
Diagnostic Lab Tests & Imaging	Deductible + 20%
Urgent Care	$75 Copay
Emergency Room	$250 Copay + 20% Coinsurance
Retail Prescriptions
Tier 1 - Generic Drugs	$20 Copay
Tier 2 - Preferred Brand Drugs	$45 Copay
Tier 3 - Non-preferred Brand Drugs	$80 Copay
Tier 4 - Specialty Drugs	N/A

Per Pay Period Cost
Employee	$151.00
Employee + Spouse	$347.91
Employee + Child(ren)	$308.25
Employee + Family	$394.85

Downloads

Summary of Benefits

Medical Benefits