Page 10 - Paragon Services Engineering 2019 Employee Benefits

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