Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums – the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Kaiser HMO HRA
Plan Information
Plan Name: Kaiser HMO HRA
Policy Number: 603152
Effective Date: 07/01/2024
Provider Network: Kaiser
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$3,000/$3,000 per individual, up to $6,000 per family
Out-of-Pocket Max (Individual/Family)
$6,000/ $6,000 per individual up to $12,000 per family
Preventive Care
$0
Primary Care Visit
30% coinsurance after deductible
Specialist Visit
30% coinsurance after deductible
Urgent Care
30% coinsurance after deductible
Emergency Room
30% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Generic
30% coinsurance (not to exceed $50)
Preferred Brand
30% coinsurance (not to exceed $100)
Non-Preferred Brand
30% coinsurance (not to exceed $100) if authorized
Specialty
30% coinsurance (not to exceed $250)
Mail-Order Rx (Up to 90-Day Supply)
Generic
30% coinsurance (not to exceed $50)
Preferred Brand
30% coinsurance (not to exceed $100)
Non-Preferred Brand
30% coinsurance (not to exceed $100) if authorized
Specialty
Not Covered
Plan Documents
Contact Information
UHC Core PPO/Select Plus PPO
Plan Information
Plan Name: UHC Core PPO/Select Plus PPO
Policy Number: 924262
Effective Date: 07/01/2024
Provider Network: UnitedHealthcare
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$3,500/$3,500 per individual, up to $7,000 per family
Out-of-Pocket Max (Individual/Family)
$7,000/$7,000 per individual up to $14,000 per family
Preventive Care
$0
Primary Care Visit
$30 Copay
Specialist Visit
$60 Copay
Urgent Care
$50 Copay
Emergency Room
30% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Tier 1 Prescription Drugs
$10 Copay
Tier 2 Prescription Drugs
$35 Copay
Tier 3 Prescription Drugs
$70 Copay
Tier 1 Specialty Prescription Drugs
$10 Copay
Tier 2 Specialty Prescription Drugs
$150 Copay
Tier 3 Specialty Prescription Drugs
$250 Copay
Mail-Order RX (Up to 90-Day Supply)
Tier 1 Prescription Drugs
$25 Copay
Tier 2 Prescription Drugs
$87.50 Copay
Tier 3 Prescription Drugs
$175
Out-of-Network
Deductible (Individual/Family)
$10,500/$10,500 per individual, up to $21,000 per family
Out-of-Pocket Max (Individual/Family)
$21,000/$21,000 per individual up to $42,000 per family
Preventive Care
Not Covered
Primary Care Visit
50% coinsurance after deductible
Specialist Visit
50% coinsurance after deductible
Urgent Care
50% coinsurance after deductible
Emergency Room
30% coinsurance after in-network deductible is met
Retail Rx (Up to 30-Day Supply)
Tier 1 Prescription Drugs
$10 Copay
Tier 2 Prescription Drugs
$35 Copay
Tier 3 Prescription Drugs
$70 Copay
Tier 1 Specialty Prescription Drugs
$10 Copay
Tier 2 Specialty Prescription Drugs
$150 Copay
Tier 3 Specialty Prescription Drugs
$250 Copay
Mail-Order RX (Up to 90-Day Supply)
Tier 1 Prescription Drugs
Not covered
Tier 2 Prescription Drugs
Not covered
Tier 3 Prescription Drugs
Not covered