Page 11 - Paragon Services Engineering 2019 Employee Benefits

Kaiser Permanente UnitedHealthcare
Plan Name Deductible HMO Select Plus HSA PPO

Network Name Kaiser Permanente Select Plus PPO Non-Network
Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited

Deductible (Annual)
- Individual $1,500 $3,000 $6,000
- Family $3,000 $6,000 $12,000
Co-Insurance (Plan Pays) 80% 80% 60%

Office Visit Copay
- Primary Care Physician $20 Copay Deductible, 20% Deductible, 40%
- Specialist Office Visit $20 Copay Deductible, 20% Deductible, 40%

Out-of-Pocket Maximum
- Individual $4,000 $5,000 $12,000
- Family $8,000 $10,000 $24,000

Hospitalization
- Inpatient Deductible, 20% $100, Deductible, 20% $100, Deductible, 40%
- Outpatient Deductible, 20% Deductible, 20% Deductible, 40%

Lab and X-Ray
- Diagnostic Deductible, $10 Copay Deductible, 20% Deductible, 40%
- Complex Deductible, 20% to $150 Deductible, 20% Deductible, 40%

Emergency Services Deductible, 20% $100, Deductible, 20%
Urgent Care $20 Copay Deductible, 20% Deductible, 40%
Preventive Care No Charge No Charge Not Covered
Deductible waived Deductible waived
Pharmacy Benefits
Pharmacy Deductible None Health Plan Deductible Applies
Retail Pharmacy
- Tier 1 $10 Copay Deductible, $10 Deductible, $10
- Tier 2 $30 Copay Deductible, $30 Deductible, $30
- Tier 3 N/A Deductible, $50 Deductible, $50
- Tier 4 20% to $200 Deductible, $30-$50 Deductible, $50
- Supply Limit 30 Days 30 Days 30 Days

Mail Order Pharmacy
- Tier 1 $20 Copay Deductible, $25 Not Covered
- Tier 2 $60 Copay Deductible, $75 Not Covered
- Tier 3 N/A Deductible, $125 Not Covered
- Tier 4 Not Covered Not Covered Not Covered
- Supply Limit 100 Days 90 Days N/A