Human Resources Benefits Unit

Western Health Advantage Deductible First HDHP

The Deductible First HDHP plan requires you to live within the plans’ Northern California service area and to receive care from Western Health Advantage providers. This means you have access to Western Health Advantage providers only, except when you need emergency care. You share in the cost of your care through co-payments, coinsurance, and deductibles.

For any service other than preventative services, a member must meet the calendar year deductible FIRST before ANY plan benefits will be paid. A member will pay 100% of the doctor office visits, radiology services, lab tests, prescriptions, hospitalizations, etc., until the calendar year deductible is met. Once the deductible is satisfied, covered medical, hospital, and prescription benefits will be provided for a copayment or coinsurance amount.

See the Medical Plan Comparison Chart for more information about deductibles, out-of-pocket maximums, and plan benefits.

Employees who have an HRA (Health Reimbursement Arrangement), or an FSA (Flexible Spending Account), may submit Western Health Advantage out-of-pocket expenses for reimbursement.

Take Note… If you (the employee) elect to enroll in this Deductible First HDHP, which qualifies as an HSA-qualified high deductible health plan, and you have a Flexible Spending Account and/or a Health Reimbursement Arrangement (HRA), be advised that under IRS rules you are NOT allowed to contribute to a Health Savings Account (HSA). Because FSA and HRA accounts can be used to reimburse your out-of-pocket medical expenses, the IRS does not allow you to also contribute to a Health Savings Account at the same time, as it is considered prohibited health coverage.

Plan InformationWestern Health Advantage Deductible First HDHP
Calendar Year DeductibleSelf-Only Enrollment: $1,300
Any One Member in a Family of Two or More: $2,600
Family of Two or More: $2,600
Calendar Year Out of Pocket Maximum
(Including Deductibles, Co-pays, and Coinsurance)
Self-Only Enrollment: $3,000
Any One Member in a Family of Two or More: $6,000
Family of Two or More: $6,000
Lifetime MaximumNone

Dependent Children Eligibility

Any Dependent Child under age 26. No age limit if disabled.

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ServiceWestern Health Advantage Deductible First HDHP
Physician & Specialist$20 copay after deductible
Preventive Care Birth to Age 18No Charge, no deductible
Preventive Care Adult Routine CareNo Charge, no deductible
Preventive Care Adult Routine OB/GYNNo Charge, no deductible
Diagnostic Lab and X-RayNo charge after deductible
Physical Therapy
(Medically necessary treatment only)
$20 copay after deductible
Chiropractic and AcupunctureNo charge after deductible
Mental Health & Substance Use Disorder
(Outpatient)

$20 copay after deductible

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ServiceWestern Health Advantage Deductible First HDHP
Inpatient Hospital and Physician Services$250 copay per admission after deductible
Outpatient Surgery$150 copay per procedure after deductible
Maternity$250 copay per admission after deductible
Emergency Room$100 copay after deductible
Ambulance$100 copay per trip after deductible
Mental Health & Substance Use Disorder
(Inpatient)
$250 copay per admission after deductible
Skilled Nursing Facility$250 copay per admission after deductible
Up to 100 days per benefit period
Home HealthNo charge after deductible up to 100 days per year

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ServiceWestern Health Advantage Deductible First HDHP
Generic or Tier 1$10 copay up to a 30 day supply after deductible
Formulary Brand or Tier 2$30 copay up to a 30 day supply after deductible
Non-Formulary Brand or Tier 3 $50 copay up to 30 day supply after deductible
Mail Order Benefit Generic or Tier 1$20 copay up to a 90 day supply after deductible
Mail Order Benefit Formulary Brand or Tier 2$60 copay up to a 90 day supply after deductible
Mail Order Benefit Non-Formulary Brand or Tier 3$100 copay up to a 90 day supply after deductible
Mandatory Mail OrderNo
Mandatory Generic ProgramYes

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Contact Information

Benefits Unit

Human Resources Department

Business Hours
Monday – Friday
8:00 AM – 5:00 PM
Contact us by Phone
Address
575 Administration Drive
Room 116 B
Santa Rosa, CA 95403
38.465237, -122.725363

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