Medical 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.

	In-Network
Deductible (Individual/Family)	$2,500 / $5,000
Member Coinsurance	20%
Out-of-Pocket Max (Individual/Family)	$5,500 / $11,000
Physician Visits
Preventive Care	Fully Covered
Primary Care Visit	$25 Copay
Specialist Visit	$75 Copay
Hospital Services
Physician Services	Deductible + 20%
Inpatient Hospitalization	Deductible + 20%
Outpatient Surgery	Deductible + 20%
Basic Outpatient Diagnostics	Deductible + 20%
Urgent Care	$50 Copay
Emergency Room	$100 Copay+Deductible+20%

Prescription Drugs	In-Network
Retail
Tier 1	$10 Copay
Tier 2	$35 Copay
Tier 3	$75 Copay
Tier 4/Specialty Drugs	$250 Copay
Mail Order
Tier 1	$25 Copay
Tier 2	$87.50 Copay
Tier 3	$187.50 Copay
Tier 4	$625 Copay

Cost Per Pay Period
Employee Only	$191.55
Employee + Spouse	$535.74
Employee + Child(ren)	$471.75
Employee + Family	$715.95

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	Core Essential Network
Deductible (Individual/Family)	$3,500/$7,000
Member Coinsurance	0%
Out-of-Pocket (Individual/Family)	$6,000 / $12,000
Physician Visits
Preventive Care	Fully Covered
Primary Care Visit	$25 Copay
Specialist Visit	$75 Copay
Hospital Services
Physician Services	Deductible
Inpatient Hospitalization	Deductible
Outpatient Surgery	Deductible
Basic Outpatient Diagnostics	Deductible
Urgent Care	$50 Copay
Emergency Room	$300 Copay, then Deductible

Prescription Drugs	Spira Care Center
Retail
Tier 1	$10 Copay
Tier 2	$35 Copay
Tier 3	$75 Copay
Tier 4	$250 Copay
Mail Order
Tier 1	$25 Copay
Tier 2	$87.50 Copay
Tier 3	$187.50 Copay
Tier 4	$625 Copay

Cost Per Pay Period
Employee Only	$108.83
Employee + Spouse	$362.04
Employee + Child(ren)	$310.47
Family	$463.68