Page 12 - Lyon Benefits Guide 01-18 CA - FINAL

[EMPLOYEE BENEFITS]

MEDICAL - HMO OPTIONS

UNITED HEALTHCARE UNITED HEALTHCARE
SELECT NETWORK HMO FULL NETWORK HMO
Network Name Signature Value Advantage Signature Value
(Smaller Network of Providers) (Larger Network of Providers)
HEALTH BENEFITS
Lifetime Maximum Unlimited Unlimited
Annual Deductible
• Individual None None
• Family None None
Coinsurance (Plan Pays) 100% 100%
Physician Office Visit
• PCP $25 Copay $25 Copay
• Specialist $25 Copay $25 Copay
• Virtual Visits $25 Copay $25 Copay
Out-of-Pocket Maximum
• Individual $1,500 $1,500
• Family $3,000 $3,000
Hospitalization
• Inpatient $500 Copay $500 Copay
• Outpatient Surgery $400 Copay $400 Copay
Lab and X-Ray
• Diagnostic No Charge No Charge
• Complex $100 Copay $100 Copay
Emergency Services $150 Copay (Waived if Admitted) $150 Copay (Waived if Admitted)
Urgent Care $25 Copay $25 Copay
($75 Copay Outside Medical Group) ($75 Copay Outside Medical Group)
Preventive Care No Charge No Charge
Chiropractic $15 Copay $15 Copay
20 Visits/Year 20 Visits/Year
Acupuncture $15 Copay $15 Copay
20 Visits/Year 20 Visits/Year
PHARMACY BENEFITS
Annual Deductible None None
Retail Pharmacy
• Generic $15 Copay $15 Copay
• Brand Name Formulary $30 Copay $30 Copay
• Brand Name Non-Formulary $45 Copay $45 Copay
• Retail Supply Limit 30 Days 30 Days
Mail Order Pharmacy
• Generic $30 Copay $30 Copay
• Brand Name Formulary $60 Copay $60 Copay
• Brand Name Non-Formulary $90 Copay $90 Copay
• Mail Order Supply Limit 90 Days 90 Days

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