MEDICAL

United Healthcare | HMO Medical Plan (CA Only)

NEW NETWORK – CA Signature Value Harmony Network With the United Healthcare Health Maintenance Organization (HMO) plan, you must choose a primary care physician (PCP) or medical group within the network. All of your care must be directed through your PCP or medical group. Any specialty care you need will be coordinated through your PCP and will generally require a referral or authorization. You will receive benefits only if you use the doctors, clinics and hospitals that belong to the medical group in which you are enrolled, except in the case of an emergency. You will be covered for urgent care services at the urgent care facilities affiliated with your assigned PCP or medical group (contact your medical group or visit their website for locations). You must select your PCP upon enrollment, or UHC will auto assign one for you.

United Healthcare HMO Network: CA Signature Value Harmony Network

United Healthcare | PPO Medical Plans

The United Healthcare Preferred Provider Organization (PPO) plans allow you to direct your own care. You are not limited to the physicians within the network, and you may self-refer to specialists. If you receive care from a physician who is a member of the network, a greater percentage of the entire cost will be paid by the insurance plan. You may also obtain services using a non‐network provider; however, you will be responsible for the difference between the covered amount and the actual charges, and you may be responsible for filing claims.

United Healthcare PPO plan options include:

Select Plus HSA PPO Network: UHC Select Plus Network
Select Plus PPO Network: UHC Select Plus Network

Click Here to search one of the UHC Networks listed above!

Kaiser Permanente | HMO Medical Plan (CA Only)

With the Kaiser Permanente Health Maintenance Organization (HMO) plan, services must be obtained at a Kaiser Permanente facility, except in the case of emergency. All of your care must be directed through your selected

doctor, but you can choose and change your doctor at any time, for any reason. Kaiser Permanente integrates all elements of healthcare such as physicians, medical centers, pharmacy, and administration in one convenient facility.

Kaiser HMO Network: Kaiser Permanente Network

Click Here to find a Kaiser Physician and/or Facility!

Resources

UHC Provider Search Instructions

UHC HMO Summary

UHC PPO Summary

UHC HSA Summary

UHC Pharmacy Drug Listing 2023

Kaiser HMO

Kaiser Telehealth Flyer

Kaiser Mental Health Flyer

UHC | Kaiser IVF Coverage

Plan Details

United Healthcare HMO Harmony Network (CA Only)

	In-Network	Out-of-Network
Deductible (Individual/Family)	$0/$0	Not Covered
Maximum Out-of-Pocket	$1,500/$3,000
Primary Care Visits	$20 Copay
Preventive Care	No Charge
Specialist Visits	$40 Copay
Emergency Room	$250 Copay
Urgent Care	$50 Copay
Rx Retail Copays
Tier 1a/1b	$10	Not Covered
Tier 2	$35
Tier 3	$70
Tier 4	N/A
Rx Mail Order
Tier 1a/1b	$25	Not Covered
Tier 2	$87.5
Tier 3	$140
Tier 4	N/A

Kaiser Permanente HMO (CA Only)

	In-Network	Out-of-Network
Deductible (Individual/Family)	$0/$0	Not Covered
Maximum Out-of-Pocket	$2,000/$4,000
Primary Care Visits	$20 Copay
Preventive Care	No Charge
Specialist Visits	$20 Copay
Emergency Room	$100 Copay
Urgent Care	$20 Copay
Rx Retail Copays
Tier 1a/1b	$15	Not Covered
Tier 2	$30
Tier 3	$30
Tier 4	30% Max $250
Rx Mail Order
Tier 1a/1b	$30 Copay	Not Covered
Tier 2	$60 Copay
Tier 3	$60 Copay
Tier 4	30% Max $250

United Healthcare HSA PPO

	In-Network	Out-of-Network
Deductible (Individual/Family)	$1,500/$3,000	$4,500/$9,000
Maximum Out-of-Pocket	$4,500/$9,000	$18,000/$36,000
Primary Care Visits	Ded, 20%	Ded, 50%
Preventive Care	Ded, 20%	Ded, 50%
Specialist Visits	Ded, 20%	Ded, 50%
Emergency Room	Ded, 20%	Ded, 50%
Urgent Care	Ded, 20%	Ded, 50%
Rx Retail Copays
Tier 1a/1b	Ded, $10	Ded, $10
Tier 2	Ded, $35	Ded, $35
Tier 3	Ded, $70	Ded, $70
Tier 4	N/A	N/A
Rx Mail Order
Tier 1a/1b	Ded, $25	Not Covered
Tier 2	Ded, $100
Tier 3	Ded, $187.50
Tier 4	Ded, 30% Max $625

United Healthcare PPO

	In-Network	Out-of-Network
Deductible (Individual/Family)	$500/$1,000	$1,500/$3,000
Maximum Out-of-Pocket	$3,500/$7,000	$10,500/$21,000
Primary Care Visits	$15 Copay	Ded, 40%
Preventive Care	No Charge	Ded, 40%
Specialist Visits	$30 Copay	Ded, 40%
Emergency Room	$100 Copay	$100 Copay
Urgent Care	$50 Copay	Ded, 40%
Rx Retail Copays
Tier 1a/1b	$10	$10
Tier 2	$35	$35
Tier 3	$70	$70
Tier 4	N/A	N/A
Rx Mail Order
Tier 1a/1b	$25	Not Covered
Tier 2	$100
Tier 3	$187.50
Tier 4	30% Max $625

Rates & Contributions

	Employee Per Month

Kaiser HMO
Employee only	$162.19
Employee + spouse	$679.43
Employee + child(ren)	$559.97
Employee + family	$847.20
CA UHC HMO
Employee only	$20.46
Employee + spouse	$315.06
Employee + child(ren)	$257.78
Employee + family	$443.96
CA UHC HSA PPO
Employee only	$95.94
Employee + spouse	$527.69
Employee + child(ren)	$431.75
Employee + family	$743.58
CA UHC PPO 500
Employee only	$205.89
Employee + spouse	$769.58
Employee + child(ren)	$629.66
Employee + family	$1,084.43
Non-CA UHC HSA PPO
Employee only	$23.99
Employee + spouse	$263.84
Employee + child(ren)	$215.88
Employee + family	$371.79
Non-CA UHC PPO 500
Employee only	$133.94
Employee + spouse	$505.73
Employee + child(ren)	$413.79
Employee + family	$712.64