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HEALTH BENEFITS: MEDICAL PLAN OPTIONS
Kaiser Permanente UnitedHealthcare
Platinum 0/15 Platinum Signature 0
HMO Plan HMO Plan
Kaiser Providers and In-Network Only
Facilities Only (Signature Value)
Plan Provisions
Lifetime Maximum Unlimited Unlimited
Annual Deductible
Individual None None
Family None None
Coinsurance (Plan Pays) 100% 100%
Out-of-Pocket Maximum
Individual $3,350 $2,500
Family $6 700 $5,000
Medical Coverage
Physician Office Visit
PCP $15 Copay $20 Copay
Specialist $30 Copay $40 Copay
Telemedicine No Charge Available through UHC Virtual Visit
Hospitalization
Inpatient $250/Day, Max 5 Days 70%
Outpatient Surgery $125 Copay 70%
Emergency Services $150 Copay 70%
Waived if Admitted Waived if Admitted
Urgent Care $15 Copay $20 Copay
Preventive Care 100% 100%
Alternative Care
Chiropractic Not Covered $15 Copay
Max 20 Visits/Year
Acupuncture $15 Copay $10 Copay
Prescription Drugs
Retail Pharmacy
– Supply Limit 30 Days 30 Days
– Generic $5 Copay Tier 1: $15 Copay
– Brand Name Formulary $15 Copay Tier 2: $35 Copay
– Brand Name Non-Formulary N/A Tier 3: $50 Copay
– Specialty 10%, Max $250 Tier 4: 25%, Max $250
Mail Order Pharmacy
– Supply Limit 100 Days 90 Days
– Generic $10 Copay Tier 1: $30 Copay
– Brand Name Formulary $30 Copay Tier 2: $70 Copay
– Brand Name Non-Formulary N/A Tier 3: $100 Copay
Tier 4: 25%, Max $500
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