Page 6 - Teacher Created Materials EE Guide 09-18 - CA

Benefits

Medical Insurance

United Healthcare United Healthcare United Healthcare
Plan Name HMO Advantage HMO Full PPO
Network Name SignatureValue SignatureValue HMO United Healthcare Non-Network
Advantage HMO Select Plus
Health Benefits

Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual $0 $0 $750 $1,500
- Family $0 $0 $1,500 $3,000
- Individual Protection N/A N/A Yes Yes

Co-Insurance (You Pay) N/A N/A 20% 40%
Office Visit Copay
- Preventive Care No Charge No Charge No Charge Not Covered
- Primary Care Physician $15 Copay $15 Copay $35 Copay Deductible, 40%
- Specialist Office Visit $30 Copay $30 Copay $35 Copay Deductible, 40%
- Urgent Care (Med Group) $15 Copay $15 Copay $125 Copay Deductible, 40%
- Urgent Care (Other) $75 Copay $75 Copay $125 Copay Deductible, 40%

Out-of-Pocket Maximum
- Individual $2,500 $2,500 $2,500 $5,000
- Family $5,000 $5,000 $5,000 $10,000
- Copays Included Yes Yes Yes Yes

Hospitalization
- Inpatient $500 Copay $500 Copay Deductible, 20% Deductible, 40%
- Outpatient $200 Copay $200 Copay Deductible, 20% Deductible, 40%
Lab and X-Ray
- Diagnostic No Charge No Charge No Charge Deductible, 40%
- Complex $100 Copay $100 Copay Deductible, 20% Deductible, 40%
Emergency Services $150 Copay $150 Copay $250 Copay
Mental Health
- Inpatient $500 Copay $500 Copay Deductible, 20% Deductible, 40%
- Outpatient $30 Copay $30 Copay $35 Copay Deductible, 40%
Pharmacy Benefits
Pharmacy Deductible $0 $0 $0 $0
Retail Pharmacy
- Generic Formulary $10 Copay $10 Copay $15 Copay $15 Copay + Difference
- Brand Name Formulary $25 Copay $25 Copay $35 Copay $35 Copay + Difference
- Non-Formulary $40 Copay $40 Copay $50 Copay $50 Copay + Difference
- Supply Limit 30 Days 30 Days 31 Days 31 Days

Mail Order Pharmacy
50
- Generic Formulary $20 Copay $20 Copay $37 Copay Not Covered
50
- Brand Name Formulary $50 Copay $50 Copay $87 Copay Not Covered
- Non-Formulary $80 Copay $80 Copay $125 Copay Not Covered
- Supply Limit 90 Days 90 Days 90 Days N/A

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