Page 10 - Paragon Services Engineering 2019 Employee Benefits Guide
P. 10

UnitedHealthcare                    UnitedHealthcare
         Plan Name                                   Harmony HMO                         Advantage HMO

         Network Name                                Harmony HMO                         Advantage HMO
         Health Benefits
         Lifetime Maximum                                Unlimited                            Unlimited

         Deductible (Annual)
          - Individual                                     None                                 None
          - Family                                         None                                 None

         Co-Insurance (Plan Pays)                          100%                                 100%
         Office Visit Copay
          - Primary Care Physician                       $30 Copay                           $15 Copay
          - Specialist Office Visit                      $40 Copay                           $30 Copay

         Out-of-Pocket Maximum
          - Individual                                    $3,500                               $2,000
          - Family                                        $7,000                               $4,000
         Hospitalization
          - Inpatient                            $750 Copay/Day, 3 day max               $250 Copay / Admit
          - Outpatient                              $350 per procedure                   $125 per procedure

         Lab and X-Ray
          - Diagnostic                                   No Charge                           No Charge
          - Complex                                  $50 Copay per test                  $500 Copay per test
         Emergency Services                             $200 Copay                           $100 Copay
         Urgent Care                                     $30 Copay                           $15 Copay

         Preventive Care                                 No Charge                           No Charge
         Pharmacy Benefits

         Pharmacy Deductible                               None                                 None
         Retail Pharmacy
          - Tier 1                                       $10 Copay                           $10 Copay
          - Tier 2                                       $30 Copay                           $30 Copay
          - Tier 3                                       $50 Copay                           $50 Copay
          - Tier 4                                      30% to $200                          30% to $200
          - Supply Limit                                  30 Days                              30 Days


         Mail Order Pharmacy
          - Tier 1                                       $20 Copay                           $20 Copay
          - Tier 2                                       $60 Copay                           $60 Copay
          - Tier 3                                      $100 Copay                           $100 Copay
          - Tier 4                                      Not Covered                         Not Covered
          - Supply Limit                                  90 Days                              90 Days
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