2024-UATP-Benefits Guide

MEDICAL, DENTAL AND VISION BENEFITS

OPTION 3 KAISER HMO

OPTION 1 BLUECHOICE HMO

OPTION 2 BLUECHOICE ADVANTAGE POS

MEDICAL BENEFIT

IN-NETWORK ONLY

IN-NETWORK

OUT-OF-NETWORK

IN-NETWORK ONLY

Annual Deductible

Individual: $0 Family: $0

Individual: $0 Family: $0

Individual: $500 Family: $1,000

Individual: $0 Family: $0

Out-of-Pocket Maximum

Individual: $1,300 Family: $2,600 Ind: $4,500 / Fam: $9,000

Individual: $1,500 Family: $3,000 Ind: $4,500 / Fam: $9,000

Individual: $3,000 Family: $6,000 Same as in-network

Individual: $1,300 Family: $2,600

Rx OOP Maximum

Preventive Care Adult Physical Exam Well-Child Care

No charge No charge

No charge No charge

30% of AB 30% of AB

No charge No charge

Physician Services Primary care physician office visits Specialist office visits Outpatient Lab & X-Ray Diagnostic test (X-ray, bloodwork) Imaging (CT/PET scans, MRIs) Emergency Care Ambulance if medically necessary Emergency room facility 1 Urgent Care

$10 copay $20 copay

$20 copay $20 copay

30% of AB* 30% of AB*

$15 copay $25 copay

No charge 2 No charge

No charge 2 No charge

30% of AB* 30% of AB*

No charge $50 copay per test

No charge $50 copay 1 $20 copay

No charge $100 copay 1 $20 copay

No charge $100 copay 1 $20 copay

$50 copay $100 copay 1 $25 copay

Hospitalization Inpatient Facility Outpatient Facility

No charge No charge

$250 copay per admission $250 copay per visit

30% of AB* 30% of AB*

$100 per admission $50 copay

Mental Health Inpatient Outpatient

No charge No charge

$250 copay per admission $20 copay per office visit

30% of AB* 30% of AB*

$100 per admission $15 copay

Prescriptions Retail Pharmacy (34 day supply) Generic / Preferred / Non-Preferred Preferred Specialty Non-Preferred Specialty

$10 / $20 / $35 3

$10 / $25 / $45 50% — $100 Maximum 50% — $150 Maximum

$10 / $25 / $45 50% — $100 Maximum 50% — $150 Maximum

$10 / $25 / $45 Not covered Not covered

*After deductible 1 Copay waived if admitted AB – Allowed benefit 2 In-network lab test benefits apply only to tests performed at LabCorp 3 Listed copays applies to Plan Pharmacies only. For non-plan pharmacy copays, see plan documents.

UATP is offering an incentive of $100 per month (payable semi - monthly) if you choose not to enroll in a medical plan.

UATP | MEDICAL BENEFITS

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