Page 7 - Vizio Sample Guide

Medical Plan Highlights

United United Healthcare United Healthcare
Healthcare Gold PPO Silver PPO HDHP (HSA)
HMO Select Plus Network Select Plus Network
Network Network Non-Network Network Non-Network
Health Benefits
Lifetime Maximum Unlimited Unlimited Unlimited
Ded (Annual)
- Individual $0 $1,500 $3,000 $2,300 $4,600
- Family $0 $3,000 $6,000 $2,800 $5,600
Out-of-Pocket Maximum
- Individual $3,500 $6,500 $13,000 $6,650 $13,300
- Family $7,000 $13,000 $26,000 $8,000 $26,600
Co-Insurance (Plan Pays) 80% 70% 50% 70% 50%

Office Visit Copay
- Preventive Care No Charge No Charge Ded, 50% No Charge Ded, 50%
- Primary Care Physician $20 Copay $0 Copay Ded, 50% Ded, 30% Ded, 50%
- Specialist Office Visit $40 Copay $75 Copay Ded, 50% Ded, 30% Ded, 50%
- Urgent Care $20 Copay $50 Copay Ded, 50% Ded, 30% Ded, 50%
- Telemedicine $5 Copay $0 Copay N/A Ded, 30% N/A

Hospitalization
- Inpatient 20% Ded, $250, 30% Ded, $250, 50% Ded, 30% Ded, 50%
- Outpatient 20% Ded, 30% Ded, 50%, limited Ded, 30% Ded, 50%, limited
$760 per date of $760 per date of
service service
Lab and X-Ray
- Diagnostic No Charge Ded, 30% Ded, 50% Ded, 30% Ded, 50%
- Complex $200 Copay Ded, 30% Ded, 50% Ded, 30% Ded, 50%
Emergency Services 20% Ded, $250 Copay, 30% Ded, 30%
Chiropractic $15 Copay $0 Copay Ded, 50% Ded, 30% Ded, 50%

20 Visits/Year 24 Visits/Year 24 Visits/Year
Pharmacy Benefits
Pharmacy Ded $0 $250, waived for $500, waived for Medical Ded Medical Ded
tier 1 tier 1 applies applies
Retail Pharmacy
- Generic Formulary $15 Copay $5 Copay $5 Copay $20 Copay $20 Copay
- Brand Name Formulary $35 Copay $50 Copay $50 Copay $50 Copay $50 Copay
- Non-Formulary $70 Copay $100 Copay $100 Copay $100 Copay $100 Copay
- Supply Limit 30 Days 30 Days 30 Days 30 Days 30 Days

Mail Order Pharmacy
- Generic Formulary Not covered $12.50 Copay Not Covered $50 Copay Not Covered
- Brand Name Formulary Not covered $125 Copay Not Covered $125 Copay Not Covered
- Non-Formulary Not covered $250 Copay Not Covered $250 Copay Not Covered
- Supply Limit Not covered 90 Days N/A 90 Days N/A

Employee Benefits 7