MEDICAL
Southern Electric Company offers the following plans through United HealthCare. Please reference the Summary Plan Description for more details.
Insurance Carrier:
United HealthCare Medical Insurance
Medical Plan:
$3,000 Deductible / 80% Coinsurance $5,000 Deductible / 80% Coinsurance
In-Network: Office Visit Copay - Primary Care Office Visit Copay - Specialist Care
$25 Copay $75 Copay $50 Copay
Deductible; then $25 Copay Deductible; then $75 Copay Deductible; then $50 Copay Deductible; then $300 Copay
Urgent Care Copay
Emergency Room Care
Deductible; then $300 Copay
Preventative Visit Copay
$0
$0
Plan Coinsurance
80%
80%
Employee Deductible
$3,000 $6,000 $8,150 $16,300
$5,000
Family Deductible
$10,000
Employee Out-of-Pocket Max
$7,000
Family Out-of-Pocket Max
$14,000
Inpatient Hospital
Deductible; then 20% Coinsurance Deductible; then 20% Coinsurance
Deductible; then 20% Coinsurance Deductible; then 20% Coinsurance
Outpatient Hospital or Facility
Out-of-Network: Coinsurance
50%
50%
Employee Deductible
$6,000
$10,000 $20,000 $14,000 $28,000
Family Deductible
$12,000 $16,300 $32,600
Employee Out-of-Pocket Max
Family Out-of-Pocket Max
Prescription Drugs: ( 30 Day Supply) Tier 1 - Generic
$10 Copay $35 Copay $75 Copay $250 Copay
$10 Copay $35 Copay $70 Copay $150 Copay
Tier 2 - Preferred
Tier 3 - Non-Preferred
Tier 4 - Specialty
Employee Weekly Deduction: Employee Only
$37.00 $147.00 $141.00 $244.00
$28.00 $118.00 $106.00 $191.00
Employee + Spouse Employee + Child(ren)
Family
5 Southern Electric Company 2024 Benefits Guide |
Made with FlippingBook - professional solution for displaying marketing and sales documents online