Page 5 - 2019 Benefits Brochure CA - Stage 1

Medical Insurance

UnitedHealthcare UnitedHealthcare
Plan Name Silver Select Plus PPO (BH-CM) Gold Select Plus (BH-CK)

Network Name In-Network Non-Network In-Network Non-Network
Health Benefits
Lifetime Maximum Unlimited Unlimited

Deductible (Annual)
- Individual $2,250 $4,500 $1,250 $2,500
- Family $4,500 $9,000 $2,500 $5,000

Co-Insurance (Plan Pays) 60% 50% 80% 50%
Office Visit Copay
- Primary Care Physician $45 Copay Deductible, 50% $25 Copay Deductible, 50%
- Specialist Office Visit $80 Copay Deductible, 50% $50 Copay Deductible, 50%

Out-of-Pocket Maximum
- Individual $7,900 $15,800 $6,000 $12,000
- Family $15,800 $31,600 $12,000 $24,000
Hospitalization
- Inpatient $250, Ded., 40% $250, Ded., 50% $250, Ded., 20% $250, Ded., 50%
- Outpatient $250, Ded., 40% $250, Ded., 50% $250, Ded., 20% $250 Ded., 50%

Lab and X-Ray
- Free Standing Deductible, 40% Deductible, 50% Deductible, 20% Deductible, 50%
- Hospital $250, Ded., 40% $250, Ded. 50% $250, Ded., 20% $250, Ded. 50%
Emergency Services Deductible, $300 Copay, 40% Deductible, $250 Copay, 20%
Urgent Care $80 Copay Deductible, 50% $75 Copay Deductible, 50%

Preventive Care No Charge Not Covered No Charge Not Covered
Chiropractic $45 Copay Deductible, 50% $25 Copay Deductible, 50%
24 Visits/Year 24 Visits/Year

Pharmacy Benefits
Pharmacy Deductible
- Individual $250 None
- Family $500 None

Retail Pharmacy
- Generic Formulary $20 Copay $20 Copay $15 Copay $15 Copay
- Brand Name Formulary $50 Copay $50 Copay $40 Copay $40 Copay
- Non-Formulary $100 Copay $100 Copay $80 Copay $80 Copay
- Supply Limit 30 Days 30 Days 30 Days 30 Days

Mail Order Pharmacy
- Generic Formulary $50 Copay Not Covered $37.50 Copay Not Covered
- Brand Name Formulary $125 Copay Not Covered $100 Copay Not Covered
- Non-Formulary $250 Copay Not Covered $200 Copay Not Covered
- Supply Limit 90 Days N/A 90 Days N/A

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