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

MEDICAL - HSA OPTION

UNITED HEALTHCARE
HDHP WITH HSA
Network Name Select Plus Non-Network
HEALTH BENEFITS
Lifetime Maximum Unlimited
Annual Deductible
• Individual $1,500 $3,500
• Family $2,700 $7,000
Coinsurance (Plan Pays) 80% 60%
Physician Office Visit
• PCP Deductible, 20% Deductible, 40%
• Specialist Deductible, 20% Deductible, 40%
• Virtual Visits Deductible, 20% Not Covered
Out-of-Pocket Maximum
• Individual $4,500 $6,000
• Family $4,500 $12,000
Hospitalization
• Inpatient Deductible, 20% Deductible, 40%
• Outpatient Surgery Deductible, 20% Deductible, 40%
Lab and X-Ray
• Diagnostic Deductible, 20% Deductible, 40%
• Complex Deductible, 20% Deductible, 40%
Emergency Services Deductible, 20%
Urgent Care Deductible, 20% Deductible, 40%

Preventive Care No Charge Not Covered
Chiropractic Deductible, 20% Deductible, 40%
24 Visits/Year
Acupuncture Deductible, 20% Deductible, 40%
12 Visits/Year
PHARMACY BENEFITS
Annual Deductible Health Deductible Applies
Retail Pharmacy
• Tier 1 $10 Copay $10 Copay
• Tier 2 $30 Copay $30 Copay
• Tier 3 $50 Copay $50 Copay
• Retail Supply Limit 30 Days 30 Days
Mail Order Pharmacy
• Tier 1 $25 Copay Not Covered
• Tier 2 $75 Copay Not Covered
• Tier 3 $125 Copay Not Covered
• Mail Order Supply Limit 90 Days N/A

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