Medical and Pharmacy Summary
This comparison of benefits is a basic summary for the medical and pharmacy plans . Refer to the Summary Plan Description for the complete schedule of benefits located on the Human Resources portal – Documents and Forms - Category Medical and Category Pharmacy . Medical coverage terminates the last day of the month in which the employee is no longer eligible for benefits . BENEFITS * In-Network Only
Calendar Year Deductible ( CYD )
Calendar Year Total Outof-Pocket Limit ( OOP ) ( deductible , co-insurance and co-pays combined )
HIGH DEDUCTIBLE PLAN ( HDHP ) EXCLUSIVE PROVIDER PLAN ( EPO )
$ 2,250 Individual $ 4,500 Family ( Individual deductible applies to employee-only coverage . For all other levels of coverage , full deductible must be met .)
$ 6,000 Individual $ 12,000 Family
$ 1,750 Individual $ 3,500 Family
$ 6,000 Individual $ 12,000 Family
Co-insurance Member pays 10 % Member pays 20 % Office Primary & Specialist After deductible met , member pays 10 % After deductible met , member pays 20 % Preventive Care Covered at 100 %; member pays $ 0 Covered at 100 %; member pays $ 0 Lab Services After deductible met , member pays 10 % After deductible met , member pays 20 % Urgent Care Center After deductible met , $ 50 co-pay $ 50 co-pay Emergency Room
After deductible met , $ 250 co-pay ( waived if admitted )
$ 250 co-pay ( waived if admitted )
Inpatient Hospital After deductible met , member pays 10 % After deductible met , member pays 20 % Outpatient Services After deductible met , member pays 10 % After deductible met , member pays 20 % Mental Health After deductible met , member pays 10 % After deductible met , member pays 20 %
Pharmacy ( local and mail order ) NOTE : Specialty Medications must be filled through Navitus SpecialtyRx - Lumicera
After deductible met , member pays 10 % Tier 1 = 15 %, Tier 2 = 25 %, Tier 3 = 40 % Specialty pharmacy = 50 %
Pharmacy ( preventive ) Preventive medications are covered 100 %; member pays $ 0 ( based on Navitus Preventive Drug List ).
Lifetime Maximum Unlimited Unlimited
* The City ’ s medical plans do not offer out-of-network coverage . All out-of-network charges are the full responsibility of the member .
Members can perform in-network provider or facility SEARCH at www . myuhc . com .
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