MEDICAL INSURANCE
Pavement Restoration offers two medical plans through United Healthcare. To find participating providers go to www.myuhc.com and click on “Find a Doctor”, then follow the prompts to complete the search. The chart below provides a brief overview of the medical plans. This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage.
If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage .
Option 1 Choice BJ77
Option 2 Choice AQQ4
Option 3 Choice AQOB
IN-NETWORK:
Plan Year April 1, 2019 – March 30. 2020
Plan Year April 1, 2019 – March 30. 2020
Plan Year April 1, 2019 – March 30. 2020
Plan Year or Calendar Year Basis
Deductible (Individual / Family)
$5,000 / $10,000
$2,000 / $4,000
$500 / $1,000
Coinsurance
70% / 30%
50% / 50%
90% / 10%
Maximum Out-of-Pocket (Individual/Family)
$6,350 / $12,700
$6,600 / $13,200
$3,500 / $7,000
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Deductible, Coinsurance & Copayments
Maximum Out-of-Pocket Includes
Lifetime Maximum
Unlimited
Unlimited
Unlimited
PREVENTIVE CARE:
Wellness Immunizations Mammography/Colonoscopy COPAYMENTS: Referral Required
Covered 100%
Covered 100%
Covered 100%
No
No
No
Office Visits Consultations for Illness/Injury
$30 Copayment
$30 Copayment
$20 Copayment
Specialist Visits
$55 Copayment
$60 Copayment
$20 Copayment
Inpatient Hospital
Deductible & Coinsurance Deductible & Coinsurance
Deductible & Coinsurance Deductible & Coinsurance
Deductible & Coinsurance Deductible & Coinsurance
Outpatient Surgery Emergency Room Urgent Care
$300 Copayment $60 Copay
$350 Copayment $100 Copay
$250 Copayment $50 Copay
OUTPATIENT DIAGNOSTIC SERVICES: Independent/Freestanding Lab Complex Diagnostic (MRI, CT, PET, Etc.) – Freestanding Facility
Deductible & Coinsurance
Covered 100%
Covered 100%
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
PRESCRIPTIONS:
Tier 1: $10 Copay Tier 2: $60 Copay Tier 3: $100 Copay
Tier 1: $10 copay Tier 2: $60 copay Tier 3: $100 copay
Tier 1: $10 copay Tier 2: $60 copay Tier 3: $100 copay
Retail (30 day supply)
OUT-OF-NETWORK Deductible
Unavailable
Unavailable
Unavailable
(Individual / Family)
Maximum Out-of-Pocket (Individual/Family)
Unavailable
Unavailable
Unavailable
Coinsurance
Unavailable
Unavailable
Unavailable
3
Made with FlippingBook - Online Brochure Maker