Medical Benefits

Insurance Provider:

 AllSavers UHC Plan# 5400-018140

Waiting Period:

1st of Month Following 30 Days

Insurance Costs & Breakdown:

Employee Only Coverage

Total Annual Cost

$7,459.20

Employer Annual Cost

$6,340.32

Employee Annual Cost

$1,118.88

Employee Cost Per Paycheck

$43.03

Employee + Spouse Coverage

Total Annual Cost

$15,268.20

Employer Annual Cost

$10,244.82

Employee Annual Cost

$5,023.38

Employee Cost Per Paycheck

$193.21

Employee + Child(ren)Coverage

Total Annual Cost

$13,848.36

Employer Annual Cost

$9,534.90

Employee Annual Cost

$4,313.46

Employee Cost Per Paycheck

$165.90

Employee + Family

Total Annual Cost

$22,367.28

Employer Annual Cost

Employee Annual Cost

$13,794.36

$8,572.92

Employee Cost Per Paycheck

$329.73

Plan Type:

Deductible:

Coinsurance:

Max Out of Pocket:

Primary Care Visit:

Specialist Visit:

Urgent Care:

Virtual Visits:

ER Facility/ER Physician:

Hospitalization:

Out-Patient Procedures:

Routine Lab/X-Ray:

Complex Imaging/Diagnostics:

RX Deductible:

RX (Tier 1/2/3/4)

RX Specialty

Non-Network Deductible:

Non-Network Coinsurance:

Non-Network Max Out of Pocket:

Teledoc:

PPO Self Funded

$5,000(Ind), $10,000 (Fam)

100% After Ded.

$6,350 (Ind), $12,700 (Fam)

$0<19 yrs old; All others $60

$60

$100

$0

$300 Copay 100% After Ded

100% After Ded

100% After Ded

100% After Ded

100% After Ded

No RX Ded

$15 / $35 / $75 / $250

N/A

$10,000 (Ind), $20,000 (Fam)

50% After Ded

$15,000 (Ind), $30,000 (Fam)

Healthiest You - See link above

Platinum Control Technologies

2822 West 5th Street

Fort Worth, TX 76107

Service Office: Midland, TX

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