Page 12 - Lyon Benefits Guide 01-18 CA - FINAL
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[EMPLOYEE BENEFITS]





          MEDICAL - HMO OPTIONS                                                                                                     MEDICAL - PPO OPTIONS






                                                      UNITED HEALTHCARE                 UNITED HEALTHCARE                                                                UNITED HEALTHCARE                      UNITED HEALTHCARE
                                                     SELECT NETWORK HMO                 FULL NETWORK HMO                                                                         PPO                              HDHP WITH HSA
           Network Name                               Signature Value Advantage              Signature Value                         Network Name                    Select Plus        Non-Network           Select Plus     Non-Network
                                                    (Smaller Network of Providers)     (Larger Network of Providers)
           HEALTH BENEFITS                                                                                                           HEALTH BENEFITS
           Lifetime Maximum                                  Unlimited                         Unlimited                             Lifetime Maximum                           Unlimited                              Unlimited
           Annual Deductible                                                                                                         Annual Deductible
           •   Individual                                     None                              None                                 •   Individual                     $500               $1,000              $1,500            $3,500
           •   Family                                         None                              None                                 •   Family                        $1,000              $2,000              $2,700            $7,000
           Coinsurance (Plan Pays)                            100%                              100%                                 Coinsurance (Plan Pays)            90%                 70%                 80%               60%
           Physician Office Visit                                                                                                    Physician Office Visit
           •   PCP                                           $25 Copay                        $25 Copay                              •   PCP                         $20 Copay         Deductible, 30%     Deductible, 20%   Deductible, 40%
           •   Specialist                                    $25 Copay                        $25 Copay                              •   Specialist                  $20 Copay         Deductible, 30%     Deductible, 20%   Deductible, 40%
           •   Virtual Visits                                $25 Copay                        $25 Copay                              •   Virtual Visits              $20 Copay          Not Covered        Deductible, 20%     Not Covered
           Out-of-Pocket Maximum                                                                                                     Out-of-Pocket Maximum
           •   Individual                                     $1,500                            $1,500                               •   Individual                    $3,000              $6,000              $4,500            $6,000
           •   Family                                         $3,000                            $3,000                               •   Family                        $6,000             $12,000              $4,500            $12,000
           Hospitalization                                                                                                           Hospitalization
           •   Inpatient                                    $500 Copay                        $500 Copay                             •   Inpatient                 Deductible, 10%     Deductible, 30%     Deductible, 20%   Deductible, 40%
           •   Outpatient Surgery                           $400 Copay                        $400 Copay                             •   Outpatient Surgery        Deductible, 10%     Deductible, 30%     Deductible, 20%   Deductible, 40%
           Lab and X-Ray                                                                                                             Lab and X-Ray
           •   Diagnostic                                   No Charge                         No Charge                              •   Diagnostic                  No Charge         Deductible, 30%     Deductible, 20%   Deductible, 40%
           •   Complex                                      $100 Copay                        $100 Copay                             •   Complex                   Deductible, 10%     Deductible, 30%     Deductible, 20%   Deductible, 40%
           Emergency Services                       $150 Copay (Waived if Admitted)  $150 Copay (Waived if Admitted)                 Emergency Services                        $100 Copay                           Deductible, 20%
           Urgent Care                                       $25 Copay                        $25 Copay                              Urgent Care                     $50 Copay         Deductible, 30%     Deductible, 20%   Deductible, 40%
                                                   ($75 Copay Outside Medical Group)  ($75 Copay Outside Medical Group)
           Preventive Care                                  No Charge                         No Charge                              Preventive Care                 No Charge          Not Covered          No Charge         Not Covered
           Chiropractic                                      $15 Copay                        $15 Copay                              Chiropractic                    $20 Copay         Deductible, 30%     Deductible, 20%   Deductible, 40%
                                                           20 Visits/Year                    20 Visits/Year                                                                   24 Visits/Year                         24 Visits/Year
           Acupuncture                                       $15 Copay                        $15 Copay                              Acupuncture                     $20 Copay         Deductible, 30%     Deductible, 20%   Deductible, 40%
                                                           20 Visits/Year                    20 Visits/Year                                                                   12 Visits/Year                         12 Visits/Year
           PHARMACY BENEFITS                                                                                                         PHARMACY BENEFITS
           Annual Deductible                                  None                              None                                 Annual Deductible                           None                           Health Deductible Applies
           Retail Pharmacy                                                                                                           Retail Pharmacy
           •   Generic                                       $15 Copay                        $15 Copay                              •   Tier 1                      $10 Copay           $10 Copay            $10 Copay         $10 Copay
           •   Brand Name Formulary                          $30 Copay                        $30 Copay                              •   Tier 2                      $25 Copay           $25 Copay            $30 Copay         $30 Copay
           •   Brand Name Non-Formulary                      $45 Copay                        $45 Copay                              •   Tier 3                      $45 Copay           $45 Copay            $50 Copay         $50 Copay
           •   Retail Supply Limit                            30 Days                          30 Days                               •   Retail Supply Limit          30 Days             30 Days              30 Days           30 Days
           Mail Order Pharmacy                                                                                                       Mail Order Pharmacy
           •   Generic                                       $30 Copay                        $30 Copay                              •   Tier 1                      $25 Copay          Not Covered           $25 Copay        Not Covered
           •   Brand Name Formulary                          $60 Copay                        $60 Copay                              •   Tier 2                     $62.50 Copay        Not Covered           $75 Copay        Not Covered
           •   Brand Name Non-Formulary                      $90 Copay                        $90 Copay                              •   Tier 3                     $112.50 Copay       Not Covered          $125 Copay        Not Covered
           •   Mail Order Supply Limit                        90 Days                          90 Days                               •   Mail Order Supply Limit      90 Days              N/A                 90 Days            N/A



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