2024 Benefits Guide - San Francisco Deluxe + Dental

Medical Plan Options

This year, you and your family can choose between three high-quality medical plans through UMR that use the UnitedHealthcare provider network and include prescription drug coverage through CVS Caremark. UMR is our Third-Party Administrator (TPA). Health benefits are often complex and can be difficult to understand, as our TPA, UMR will process claims, answer questions and other important management functions related to our health plans.

We suggest all employees review the plan options, including the UnitedHealthcare (UHC) and CVS Caremark networks to see if your current providers, pharmacies and medications are still in-network. See the Medical Plan Resources page for instructions on locating an in-network provider.

Back To The Full Benefits Guide

Exclusive Provider Organization (EPO)

Provides in-network coverage only
You pay copays for office visits
You can pair this plan with an FSA to help pay for out-of-pocket expenses with pre-tax funds

Preferred Provider Organization (PPO)

Provides in- and out-of-network coverage, but you will get a greater level of coverage and it will typically cost you less to stay in-network
You pay copays for in-network office visits
You can pair this plan with an FSA to help pay for out-of-pocket expenses with pre-tax funds

CVS Caremark

All the TCWGlobal medical plans include a Pharmacy Benefits Manager (PBM) to manage all your prescription drug needs. The new pharmacy benefits cover generic, brand-name formulary, non-formulary brand and specialty drugs. The best way to save on prescriptions is to use generic or over the counter medications as opposed to brand name drugs. When you use generic medications, you will pay the lowest copay. Click here for a full list of covered medications and tier level.

To locate a participating pharmacy in your area or to price out the cost of prescription medications, call 800-237-2767 or visit caremark.com.

Deductibles &
Out-of-Pocket Maximum

	Select EPO	Preferred PPO		Choice PPO
	In-Network	In-Network	Out-of-Network	In-Network	Out-of-Network

Calendar Year Deductible

Individual	$1,500	$1,500	$3,000	$5,900	$11,800
Family	$3,000	$3,000	$6,000	$11,800	$23,600

Calendar Year Out-of-Pocket Maximum
(Out-of-Pocket Maximum Includes Deductible)

Individual	$5,000	$4,000	$8,000	$6350	$12,700
Family	$10,000	$8,000	$16,000	$12,700	$25,400

Coinsurance/Copays
(What you will pay)

	Select EPO	Preferred PPO		Choice PPO
	In-Network	In-Network	Out-of-Network	In-Network	Out-of-Network

Preventative Care	No Charge	No Charge	Plan pays 50% after deductible	No Charge	Plan pays 50% after deductible
Primary Care Physician	$25	$30	Plan pays 50% after deductible	$35	Plan pays 50% after deductible
Specialist	$40	$30	Plan pays 50% after deductible	$35	Plan pays 50% after deductible
Mental Health Outpatient Office	$25	$30	Plan pays 50% after deductible	No Charge	Plan pays 50% after deductible
Laboratory and Radiology (Benefits are covered based on where service is provided)	No Charge	No Charge	Plan pays 50% after deductible	No Charge	Plan pays 50% after deductible
Advanced Imaging (Benefits are covered based on where service is provided)	Plan pays 70% after deductible	Plan pays 80% after deductible	Plan pays 50% after deductible	No charge after deductible	Plan pays 50% after deductible
Urgent Care Facility	$25	$125	Plan pays 50% after deductible	No charge after deductible	Plan pays 50% after deductible
Emergency Room	$150 (waived if admitted)	$250 (waived after admitted)		No charge after deductible
Inpatient Hospital Care	Plan pays 70% after deductible	Plan pays 80% after deductible	Plan pays 50% after deductible	No charge after deductible	Plan pays 50% after deductible
Outpatient Surgery Facility	Plan pays 70% after deductible	Plan pays 80% after deductible	Plan pays 50% after deductible	No charge after deductible	Plan pays 50% after deductible

Pharmacy

	Select EPO	Preferred PPO		Choice PPO
	In-Network	In-Network	Out-of-Network	In-Network	Out-of-Network

Retail RX (Up to 30-days supply)

Generic	$20	$10	Plan pays 80%	$10	Plan pays 80%
Preferred Brand	$35	$30		$30
Non-Preferred Brand	$50	$50		$50

Mail Order RX (up to 90-days supply)

Generic	$40	$25	Not Covered	$25	Not Covered
Preferred Brand	$70	$75		$75
Non-Preferred Brand	$100	$125		$125

Get Started with UMR

The UMR app has a smart fresh look, simple navigation, and faster access to your health care benefits information. View your plan details on demand - anytime, anywhere.

With a single tap, you can:

Access your digital ID card
Look up in-network health care providers
Find out if there’s a co-pay for your upcoming appointment
View your recent medical and dental claims
Chat, call or message UMR’s member support team

Scan the code to download the app!

Asset 2-QR Code

Find a Provider

Go to the UHC Provider Locator
Update the location by selecting by a street address city & state, zip code, or
county
Either search for a provider or service, or find care by selecting one category:
- People
- Places
- Services and Treatments
- Care by Condition
- Cost Estimates

Medical Plan Resources

Get the Care You Need

Teladoc gives you access 24 hours, 7 days a week to a U.S. board-certified doctor through the convenience of phone, video or mobile app visits. It’s an affordable option for quality medical care.

Teladoc doctors can treat many medical conditions including:

Cold & flu symptoms
Allergies
Pink Eye
Respiratory infection
Sinus problems
Skin problems
And more!

Talk to a doctor anytime, anywhere you happen to be

Receive quality care via phone or mobile app

Prompt treatment, talk to a doctor in minutes

A network of doctors that can treat every member of the family

Prescriptions sent to a pharmacy of choice if medically necessary

Teledoc is less expensive than the ER or urgent care

Mental Health

Behavioral and Mental Health Support

Whatever is on your mind, get the help you need. With Talkspace online therapy, you can regularly communicate with a therapist, safely and securely from your phone or desktop 24/7. No office visit required.

You can also access Talkspace Psychiatry to schedule live video sessions with a psychiatrist trained in mental health care and prescription management for a tailored treatment plan.

Simply register (first visit only) and choose a provider and message anywhere, anytime at talkspace.com/connect. After you register, download the Talkspace app on your mobile phone. Talkspace is supported by Chrome, FireFox, Safari or Edge browsers on your desktop computer. Talkspace is your space to use in your time. It’s covered under your plan’s behavioral health benefits.**

Support for anxiety, depression, PTSD, substance use disorders, eating disorders, compulsive disorders and other conditions
Specialized clinicians delivering services across all 50 states and are matched to members based on location, needs and preferences

Find a therapist with an online matching tool

Start therapy within hours of choosing your therapist

Choose real-time face-to-face video visits by appointment, when needed

Employee Assistance Plan (EAP) with UNUM

All employees have access to our EAP at no cost to you. The EAP offers support for a wide range of work and personal issues to promote a healthy work/life balance. You typically have three free, confidential sessions per issue. Counselors are also available for referrals for additional care or to help with child/elder care services, finances, personal and legal issues.

Get help 24/7 from UNUM

UNUM.com

800-854-1446

Employee Only	$0.00
Employee + Spouse	$146.64
Employee + Child(ren)	$139.31
Employee + Family	$312.42

2024 Benefits Guide - San Francisco Deluxe + Dental

Medical Plan Options

Looking for Mental Health Info?

Exclusive Provider Organization (EPO)

Preferred Provider Organization (PPO)

CVS Caremark

We're Here to Help!

Weekly Medical Costs

Tier

Preferred PPO

Employee Only

Employee + Spouse

Employee + Child(ren)

Employee + Family

Coverage may be terminated for failure to timely pay premiums via payroll.

Deductibles & Out-of-Pocket Maximum

Select EPO

Preferred PPO

Choice PPO

In-Network

In-Network

Out-of-Network

In-Network

Out-of-Network

Calendar Year Deductible

Individual

Family

Calendar Year Out-of-Pocket Maximum (Out-of-Pocket Maximum Includes Deductible)

Individual

Family

Coinsurance/Copays (What you will pay)

Select EPO

Preferred PPO

Choice PPO

In-Network

In-Network

Out-of-Network

In-Network

Out-of-Network

Preventative Care

Primary Care Physician

Specialist

Mental Health Outpatient Office

Laboratory and Radiology

Advanced Imaging

Urgent Care Facility

Emergency Room

Inpatient Hospital Care

Outpatient Surgery Facility

Pharmacy

Select EPO

Preferred PPO

Choice PPO

In-Network

In-Network

Out-of-Network

In-Network

Out-of-Network

Retail RX (Up to 30-days supply)

Generic

Preferred Brand

Non-Preferred Brand

Mail Order RX (up to 90-days supply)

Generic

Preferred Brand

Non-Preferred Brand

Need More Information?

Get Started with UMR

Scan the code to download the app!

Find a Provider

Medical Plan Resources

Get the Care You Need

Teladoc doctors can treat many medical conditions including:

Mental Health

Behavioral and Mental Health Support

Employee Assistance Plan (EAP) with UNUM

Get help 24/7 from UNUM

Check Out the Full Benefits Guide

Deductibles &
Out-of-Pocket Maximum

Calendar Year Out-of-Pocket Maximum
(Out-of-Pocket Maximum Includes Deductible)

Coinsurance/Copays
(What you will pay)