Page 6 - Monster Energy 2021-2022 Benefits Guide

MEDICAL PLAN OPTIONS

CALIFORNIA-ONLY HMO PLANS ALL STATES PPO PLANS

UNITEDHEALTHCARE UNITEDHEALTHCARE
KAISER SIGNATURE UNITEDHEALTHCARE SELECT PLUS HSA
PERMANENTE HMO SELECT PLUS
VALUE HMO (EXCLUDING HI)
Kaiser In-Network In-Network Out-of-Network In-Network Out-of-Network
Providers Only Coverage Only

Calendar Year $250/member; $1,500/member; $3,500/member;
Deductible None None $500/family $2,800/family $7,000/family
Annual Out-of- $1,500/member; $1,000/member; $2,000/member; $10,000/member; $2,800/member; $4,500/member;
Pocket Maximum $3,000/family $2,000/family $4,000/family $20,000/family $5,200/family $9,000/family

$10 Copay — primary care 30% 10% after 30% after
Office Visit $10 Copay $15 Copay
$30 Copay — specialist after deductible deductible deductible
Routine Physical Plan pays 100% Plan pays 100% Plan pays 100% Not covered Plan pays 100% Not covered
Exams
Inpatient 10% 30% 10% 30%
Hospital Care Plan pays 100% Plan pays 100% after deductible after deductible after deductible after deductible
10% 30% 10% 30%
Outpatient Surgery $10 Copay Plan pays 100%
after deductible after deductible after deductible after deductible
Mental Health*
$10 Copay $10 Copay 10% after deductible 10% after deductible
• Inpatient hospital $5 Copay per group visit
• Outpatient care $10 Copay $10 Copay $15 Copay 10% after deductible

Emergency $100 Copay, $100 Copay, $100 Copay,
Room Services waived if admitted waived if admitted then 10% after deductible if admitted 10% after deductible

After deductible: After deductible:
Generic $10 Generic $10 Generic $10
Retail Prescription Brand $20 Generic $10 Brand $20 Brand $20 Generic $10 Generic $10
Drugs Copays Brand $20 Brand $35 Brand $35
(30-day supply) Non-formulary Non-formulary $30 Non-formulary Non-formulary Non-formulary Non-formulary
$10 Generic, $20 Brand $35 $35
$60 $60
After deductible:
Generic $20 Generic $20
Mail Order Generic $20 Generic $25
Prescription Brand $40 Brand $40 Not Not
Drugs (90- or Non-formulary Brand $40 Non-formulary Available Brand $87.50 Available
100-day supply) $20 Generic, $40 Brand Non-formulary $60 $70 Non-formulary
$150
Prescription Kaiser UnitedHealthcare
YOUR Permanente HMO SignatureValue HMO UnitedHealthcare Select Plus UnitedHealthcare Select Plus HSA
BI-WEEKLY
COST
California Only California Only CA PPO Non-CA PPO All States except HI

$0.00 $0.00 $0.00 $0.00
Employee Only $34.62
(100% company paid) (100% company paid) (100% company paid) (100% company paid)
Employee + Spouse $138.46 $138.46 $159.23 $152.31 $120.00

Employee + Child(ren) $110.77 $110.77 $143.08 $138.46 $96.00

Employee + Family $186.92 $186.92 $237.69 $223.85 $159.23

6 /