Page 6 - California Eye Management EE Guide 2020

Medical Benefits

United HealthCare United HealthCare
Plan Name Harmony HMO Signature Value HMO

Network In-Network In-Network
Health Benefits Includes a Concierge Service

Lifetime Maximum Unlimited Unlimited
Deductible (Annual) $500 / member $1,000 / member
$1,000 / family $2,000 / family
Office Visit Copay
- Primary Care Physician $20 Copay $25 Copay
- Specialist Office Visit $35 Copay $40 Copay
- Online Visit $20 Copay $25 Copay
Out-of-Pocket Maximum

- Individual $3,000 $4,500
- Family $6,000 $9,000

Hospitalization
- Inpatient Deductible, 30% Deductible, 30%
- Outpatient Deductible, 30% Deductible, 30%

Lab and X-Ray
- Preventive Screenings No charge No charge
- Laboratory Services $20 Copay $25 Copay
- Specialized Scanning and Imaging $100 Copay $100 Copay
Emergency Services $150 Copay $150 Copay
Urgent Care $20 Copay $25 Copay

Preventive Care No charge No Charge
Chiropractic / Acupuncture $15 Copay (Self-Refer) $10 Copay (Self-Refer)
Rider Refer to AAM Rider Summary Refer to AGV Rider Summary
Combined 20 visit limit per benefit period Combined 40 visit limit per benefit period

Pharmacy Benefits

Pharmacy Deductible None None
Retail Pharmacy
- Tier 1A / Tier 1B $15 Copay $15 Copay
- Tier 2 $40 Copay $40 Copay
- Tier 3 $75 Copay $70 Copay
- Tier 4 N/A N/A
- Supply Limit 30 Days 30 Days

Mail Order Pharmacy
- Tier 1A / Tier 1B $30 Copay $30 Copay
- Tier 2 $80 Copay $80 Copay
- Tier 3 $150 Copay $140 Copay
- Tier 4 N/A N/A
- Supply Limit 90 Days 90 Days

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