Page 13 - Lyon Benefits Guide 01-18 CA - FINAL

MEDICAL - PPO OPTIONS

UNITED HEALTHCARE UNITED HEALTHCARE
PPO HDHP WITH HSA
Network Name Select Plus Non-Network Select Plus Non-Network

HEALTH BENEFITS
Lifetime Maximum Unlimited Unlimited
Annual Deductible
• Individual $500 $1,000 $1,500 $3,500
• Family $1,000 $2,000 $2,700 $7,000
Coinsurance (Plan Pays) 90% 70% 80% 60%
Physician Office Visit
• PCP $20 Copay Deductible, 30% Deductible, 20% Deductible, 40%
• Specialist $20 Copay Deductible, 30% Deductible, 20% Deductible, 40%
• Virtual Visits $20 Copay Not Covered Deductible, 20% Not Covered
Out-of-Pocket Maximum
• Individual $3,000 $6,000 $4,500 $6,000
• Family $6,000 $12,000 $4,500 $12,000
Hospitalization
• Inpatient Deductible, 10% Deductible, 30% Deductible, 20% Deductible, 40%
• Outpatient Surgery Deductible, 10% Deductible, 30% Deductible, 20% Deductible, 40%
Lab and X-Ray
• Diagnostic No Charge Deductible, 30% Deductible, 20% Deductible, 40%
• Complex Deductible, 10% Deductible, 30% Deductible, 20% Deductible, 40%
Emergency Services $100 Copay Deductible, 20%
Urgent Care $50 Copay Deductible, 30% Deductible, 20% Deductible, 40%

Preventive Care No Charge Not Covered No Charge Not Covered
Chiropractic $20 Copay Deductible, 30% Deductible, 20% Deductible, 40%
24 Visits/Year 24 Visits/Year
Acupuncture $20 Copay Deductible, 30% Deductible, 20% Deductible, 40%
12 Visits/Year 12 Visits/Year
PHARMACY BENEFITS
Annual Deductible None Health Deductible Applies
Retail Pharmacy
• Tier 1 $10 Copay $10 Copay $10 Copay $10 Copay
• Tier 2 $25 Copay $25 Copay $30 Copay $30 Copay
• Tier 3 $45 Copay $45 Copay $50 Copay $50 Copay
• Retail Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
• Tier 1 $25 Copay Not Covered $25 Copay Not Covered
• Tier 2 $62.50 Copay Not Covered $75 Copay Not Covered
• Tier 3 $112.50 Copay Not Covered $125 Copay Not Covered
• Mail Order Supply Limit 90 Days N/A 90 Days N/A

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