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