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UHA PPO Plan* Kaiser HMO
Medical Services In-Network Out-of-Network In-Network Only
Calendar Year Deductible
Individual/Family None None None
Out-of-Pocket Maximum
includes Rx? No No Yes
Individual $2,500 $2,500
Family $7,500 $7,500
Physician Services
Preventive Care 100% 100% 100%
PCP Visit 10% 30% $20 copay
Specialist Visit 10% 30% $20 copay
Acupuncture $10 copay; $20 copay; limited
and Chiropractic limited to $500 to 12 visits
Services combined
benefit per year
Hospital Services
Inpatient 10% 30% 10%
Emergency 10% 10% $100 copay
Room
Outpatient 10% 30% 10%
Outpatient 20% 30% $10 copay; 20%
Diagnostic for specialty labs/
Testing And Lab testing
Services
Prescription Services
Prescription Drug Copay Maximum
Individual $4,850 Not covered Included with
Family $7,200 Not covered medical
Generic $10 copay Not covered Generic
Maintenance—$3
copay; other
generic $10 copay
Preferred Brand $20copay 30% $45 copay
Non-Preferred $40 copay 30% Limited to
Brand preferred only
Specialty Drugs $250 or 30% $200 copay
more, 20%
Wellness Benefits N/a N/a Fit rewards—$200
gym, $10 home
* See UHA plan summary for full details
** See Kaiser plan summary for full details
*** Member pays the cost difference if a brand name drug is requested when a generic
equivalent is available
14 2019 Benefits Guide
Medical Services In-Network Out-of-Network In-Network Only
Calendar Year Deductible
Individual/Family None None None
Out-of-Pocket Maximum
includes Rx? No No Yes
Individual $2,500 $2,500
Family $7,500 $7,500
Physician Services
Preventive Care 100% 100% 100%
PCP Visit 10% 30% $20 copay
Specialist Visit 10% 30% $20 copay
Acupuncture $10 copay; $20 copay; limited
and Chiropractic limited to $500 to 12 visits
Services combined
benefit per year
Hospital Services
Inpatient 10% 30% 10%
Emergency 10% 10% $100 copay
Room
Outpatient 10% 30% 10%
Outpatient 20% 30% $10 copay; 20%
Diagnostic for specialty labs/
Testing And Lab testing
Services
Prescription Services
Prescription Drug Copay Maximum
Individual $4,850 Not covered Included with
Family $7,200 Not covered medical
Generic $10 copay Not covered Generic
Maintenance—$3
copay; other
generic $10 copay
Preferred Brand $20copay 30% $45 copay
Non-Preferred $40 copay 30% Limited to
Brand preferred only
Specialty Drugs $250 or 30% $200 copay
more, 20%
Wellness Benefits N/a N/a Fit rewards—$200
gym, $10 home
* See UHA plan summary for full details
** See Kaiser plan summary for full details
*** Member pays the cost difference if a brand name drug is requested when a generic
equivalent is available
14 2019 Benefits Guide
