Page 13 - Lyon Benefits Guide 01-18 CA - FINAL

[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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