Value Plan ( Previously HDHP )
Core Plan ( Previously EPO )
MEDICAL AND PHARMACY PLAN SUMMARY
This comparison of benefits is a basic summary only . Refer to the Human Resources portal for the plan document . Changes have been made to the names of the plans , however coverages and benefits remain the same .
Benefits ( In-Network Only ) 1
Calendar Year Deductible ( CYD )
Value Plan ( Previously HDHP )
$ 2,250 Individual 2 $ 4,500 Family
Core Plan ( Previously EPO )
$ 1,750 Individual $ 3,500 Family
Calendar Year Total Out-of-Pocket
Limit ( Deductible , co-insurance and co-pays combined )
$ 6,000 Individual $ 12,000 Family
$ 6,000 Individual $ 12,000 Family
Co-insurance Member pays 10 % Member pays 20 % Office Primary & Specialist
After deductiblemet , memberpays 10 %
After deductible met , member pays
20 % Preventive Care Covered at 100 %; member pays $ 0 Covered at 100 %; member pays $ 0
Care ATC Health and Wellness Center
Lab Services
$ 40 for office visit
After deductible / out-of-pocket max is met , $ 0 After deductiblemet , memberpays 10 %
$ 0 for office visit ( no deductible requirement )
After deductible met , member pays
20 % Urgent Care Center After deductible met , $ 50 co-pay $ 50 co-pay
Emergency Room Inpatient Hospital Outpatient Services Mental Health
Pharmacy ( local and mail order ) NOTE : Specialty Medications must be filled through Navitus SpecialtyRx - Lumicera
After deductible met , $ 250 co-pay ( waived if admitted )
After deductible met , member pays 10 %
$ 250 co-pay ( waived if admitted )
After deductible met , member pays 20 %
Tier 1 = 15 % Tier 2 = 25 % Tier 3 = 40 %
Specialty Pharmacy = 50 % Pharmacy ( preventive ) Members pay $ 0 for preventive medications ( See Navitus Preventive Drug List ) Lifetime Maximum
Unlimited
1
The City plans do not offer out-of-network coverage . You will be responsible for any expenses that you incur outside of the UHC network .
2
Individual deductible applies to employee-only level of coverage . For all other levels of coverage , you must meet the full deductible amount .
City of Arlington / EMPLOYEE BENEFITS GUIDE 2021
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