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.
UHC HSA HDHP
Plan Information
Plan Name: UHC HSA HDHP
Policy Number: 911464
Effective Date: 07/01/2025
Provider Network: Select Plus
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,650/$3,300
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
No charge
Primary Care Visit
10% coinsurance after deductible
Specialist Visit
10% coinsurance after deductible
Urgent Care
10% coinsurance after deductible
Emergency Room
10% coinsurance after deductible
Retail Rx (Up to 31-Day Supply)
Tier 1
$10 after deductible
Tier 2
$35 after deductible
Tier 3
$70 after deductible
Specialty
Tier 1: $10 after deductible
Tier 2: $150 after deductible
Tier 3: $250 after deductible
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
$25 after deductible
Tier 2
$87.50 after deductible
Tier 3
$175 after deductible
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$4,500/$9,000
Out-of-Pocket Max (Individual/Family)
$18,000/$36,000
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
10% coinsurance after deductible
Retail Rx (Up to 31-Day Supply)
Tier 1
$10 after deductible
Tier 2
$35 after deductible
Tier 3
$70 after deductible
Specialty
Tier 1: $10 after deductible
Tier 2: $150 after deductible
Tier 3: $250 after deductible
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
Not covered
Tier 2
Not covered
Tier 3
Not covered
Specialty
Not covered
Plan Documents
Contact Information
UHC Buy Up PPO Plan
Plan Information
Plan Name: UHC Buy Up PPO Plan
Policy Number: 911464
Effective Date: 07/01/2025
Provider Network: Select Plus
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$2,500/$5,000
Preventive Care
No charge
Primary Care Visit
$15
Specialist Visit
$30
Urgent Care
$50
Emergency Room
20% coinsurance after deductible
Retail Rx (Up to 31-Day Supply)
Tier 1
$5
Tier 2
$30
Tier 3
$65
Specialty
Tier 1: $5
Tier 2: $150
Tier 3: $250
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
$12.50
Tier 2
$75
Tier 3
$162.50
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$1,500/$3,000
Out-of-Pocket Max (Individual/Family)
$7,500/$15,000
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
20% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Tier 1
$5
Tier 2
$30
Tier 3
$65
Specialty
Tier 1: $5
Tier 2: $150
Tier 3: $250
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
Not covered
Tier 2
Not covered
Tier 3
Not covered
Specialty
Not covered
Plan Documents
Contact Information
UHC Base PPO Plan
Plan Information
Plan Name: UHC Base PPO Plan
Policy Number: 911464
Effective Date: 07/01/2025
Provider Network: Select Plus
Benefit Highlights
In-Network
Deductible (Individual/Family)
$2,000/$4,000
Out-of-Pocket Max (Individual/Family)
$5,000/$10,000
Preventive Care
No charge
Primary Care Visit
$30
Specialist Visit
$60
Urgent Care
$50
Emergency Room
20% coinsurance after deductible
Retail Rx (Up to 31-Day Supply)
Tier 1
$5
Tier 2
$30
Tier 3
$65
Specialty
Tier 1: $5
Tier 2: $150
Tier 3: $250
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
$12.50
Tier 2
$75
Tier 3
$162.50
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$6,000/$12,000
Out-of-Pocket Max (Individual/Family)
$15,000/$30,000
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
20% coinsurance after deductible
Retail Rx (Up to 30-Day Supply)
Tier 1
$5
Tier 2
$30
Tier 3
$65
Specialty
Tier 1: $5
Tier 2: $150
Tier 3: $250
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
Not covered
Tier 2
Not covered
Tier 3
Not covered
Specialty
Not covered
Plan Documents
Contact Information
Kaiser HMO (CA Only)
Plan Information
Plan Name: Kaiser HMO
Northern CA Policy: 39880
Southern CA Policy: 231360
Effective Date: 07/01/2025
Provider Network: Kaiser
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
No charge
Primary Care Visit
$30
Specialist Visit
$40
Urgent Care
$30
Emergency Room
$100
Retail Rx (Up to 30-Day Supply)
Generic
$10
Preferred Brand
$30
Non-Preferred Brand
$30
Specialty
20% coinsurance up to $250
Mail-Order RX (Up to 90-Day Supply)
Generic
$20
Preferred Brand
$60
Non-Preferred Brand
$60
Specialty
20% coinsurance up to $250