Page 10 - Paragon Services Engineering 2019 Employee Benefits
P. 10

UnitedHealthcare                    UnitedHealthcare
         Plan Name                                   Harmony HMO                         Advantage HMO

         Network Name                                Harmony HMO                         Advantage HMO
         Health Benefits
         Lifetime Maximum                                Unlimited                            Unlimited

         Deductible (Annual)
          - Individual                                     None                                 None
          - Family                                         None                                 None

         Co-Insurance (Plan Pays)                          100%                                 100%
         Office Visit Copay
          - Primary Care Physician                       $30 Copay                           $15 Copay
          - Specialist Office Visit                      $40 Copay                           $30 Copay

         Out-of-Pocket Maximum
          - Individual                                    $3,500                               $2,000
          - Family                                        $7,000                               $4,000
         Hospitalization
          - Inpatient                            $750 Copay/Day, 3 day max               $250 Copay / Admit
          - Outpatient                              $350 per procedure                   $125 per procedure

         Lab and X-Ray
          - Diagnostic                                   No Charge                           No Charge
          - Complex                                 $100 Copay per test                  $100 Copay per test
         Emergency Services                             $200 Copay                           $100 Copay
         Urgent Care                                     $30 Copay                           $15 Copay

         Preventive Care                                 No Charge                           No Charge
         Pharmacy Benefits

         Pharmacy Deductible                               None                                 None
         Retail Pharmacy
          - Tier 1                                       $10 Copay                           $10 Copay
          - Tier 2                                       $30 Copay                           $30 Copay
          - Tier 3                                       $50 Copay                           $50 Copay
          - Tier 4                                      30% to $200                          30% to $200
          - Supply Limit                                  30 Days                              30 Days


         Mail Order Pharmacy
          - Tier 1                                       $20 Copay                           $20 Copay
          - Tier 2                                       $60 Copay                           $60 Copay
          - Tier 3                                      $100 Copay                           $100 Copay
          - Tier 4                                      Not Covered                         Not Covered
          - Supply Limit                                  90 Days                              90 Days
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