2022 Benefits Guide - CSHL

Your Medical Benefits and Contributions

CSHL health plans are administered by United Healthcare (UHC). Medical Insurance United Healthcare Choice Tiered Plan

Choice Plus Plan

Member pays:

Member pays:

Medical Benefits

In-Network Out-of-Network

In-Network

Out-of-Network

Preventive Services

No charge

No coverage

No charge

20% after DED

PCP/Specialist Office Visit: Tier 1 PCP/Specialist Office Visit: Non-Designated

$20

No coverage

$40

20% after DED

$35

No coverage

$40

20% after DED

Physical Therapy

$20 $50

No coverage No coverage No coverage No coverage

$40 $50

20% after DED 20% after DED

Urgent Care Facility Emergency Room Inpatient Hospital

$150 $500

$150

$150

$1,000

20% after DED

Deductible (DED) : Single/ Family (calendar year)

$250/$500

No coverage

$500/$1,200

$1,000/$2,400

Coinsurance

See below

No coverage

20%

20%

Outpatient Surgery:

Alternate Facility

0% - No DED No coverage $250 co-pay per occurrence – 0% No coverage

20% after DED 20% after DED

Hospital Based

20% after DED 20% after DED

Laboratory Services:

Alternate Facility

0% - No DED No coverage 20% after DED No coverage

20% after DED 20% after DED 20% after DED 20% after DED

Hospital Based

Radiology Services:

Alternate Facility Hospital Based

0% - No DED No coverage 20% after DED No coverage

20% after DED 20% after DED 20% after DED 20% after DED

Out-of-Pocket Maximum $3,000/$6,000

No coverage

$3,350/$6,700

$5,000/$10,000

Prescription Drug Benefits – Tier 1 / Tier 2 / Tier 3

Retail (up to 31 days)

$10/$35/$55 $20/$70/$110

No coverage No coverage

$10/$35/$55 $20/$70/$110

$10/$35/$55 No coverage

Mail Order (up to 90 days)

Specialty Drugs

Need to be obtained through OptumRx

Employee Monthly Pre-Tax Contributions Choice Tiered Plan Full-Time Choice Tiered Plan Part-Time

Choice Plus Plan Full-Time

Choice Plus Plan Part-Time

Employee Only

$103.00

$178.50

$272.50

$340.50

Employee+Spouse/Domestic Partner

$224.50

$348.00

$544.50

$680.50

Employee + Child(ren) Employee + Family

$195.00 $340.00

$301.50 $526.00

$520.00 $803.00

$650.00

$1,003.50 For more information on your plan benefits please see your Summary of Benefits Coverage (SBC) and/or Summary Plan Description (SPD) which can be found on the HR Intranet. To locate Tier 1 network providers, or to access the Prescription Drug List, visit www.myuhc.com.

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