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

[EMPLOYEE BENEFITS]

MEDICAL - PPO OPTION

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

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

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