Page 7 - AMT Gordian CA EE Guide 01-2020
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BENEFITS
Medical Insurance
United Healthcare Kaiser Permanente
Plan Name HMO Y8V Traditional HMO
Network Name Signature Value Kaiser Permanente
Health Benefits
Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $0 $0
- Family $0 $0
Out-of-Pocket Maximum
- Individual $2,500 $1,500
- Family $5,000 $3,000
Co-Insurance (Plan Pays) 100% 100%
Office Visit Copay
- Preventive Care No Charge No Charge
- Primary Care Physician $30 Copay $20 Copay
- Specialist Office Visit $40 Copay $35 Copay
- Urgent Care $30-$50 Copay $20 Copay
- Virtual Visits $25 Copay $0
Hospitalization
- Inpatient $500 Copay $250 Copay
- Outpatient Surgery $250 Copay $35 Copay
Lab and X-Ray
- Diagnostic No Charge No Charge
- Complex $50-$100 Copay No Charge
Emergency Services $100 Copay $100 Copay
Chiropractic $15 Copay $15 Copay
20 Visits/Year 20 Visits/Year
Pharmacy Benefits
Pharmacy Deductible
- Individual $0 $0
- Family $0 $0
Retail Pharmacy
- Generic Formulary $10 Copay $10 Copay
- Brand Name Formulary $30 Copay $35 Copay
- Non-Formulary $50 Copay N/A
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
- Generic Formulary $20 Copay $20 Copay
- Brand Name Formulary $60 Copay $70 Copay
- Non-Formulary $100 Copay N/A
- Supply Limit 90 Days 100 Days
Specialty 30% Max $200 Copay 20% Max $150 Copay
- Supply Limit 30 Days 30 Days
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