Pavement Restoration 2019

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

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