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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% $15 copay
Specialist Visit 10% 30% $15 copay
Acupuncture $10 copay; limited $20 copay;
and Chiropractic to $500 combined limited to 12 visits
Services beneit per year

Hospital Services
Inpatient 10% 30% 10%

Emergency Room 10% 10% $100 copay
Outpatient 10% 30% 10%
Outpatient 20% 30% $10 copay;
Diagnostic Testing 20% for specialty
And Lab Services labs/testing

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 $20 copay 30% $45 copay
Non-Preferred $40 copay 30% Limited to preferred
Brand only
Specialty Drugs $250 or 30% $200 copay
more, 20%
Wellness Beneits 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 diference if a brand name drug is requested when a generic
equivalent is available

14 2020 Benefits Guide