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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.
Medical Plan SummaryPremium Rates
For Employees
Employee Semi Monthly Medical Plan Premiums
Extra-Help Semi Monthly Medical Plan Premiums
For Retirees
Medical Plan Summary
| Plan Information | Western Health Advantage Deductible First HDHP |
|---|---|
| Calendar Year Deductible | Self-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 Maximum | None |
Dependent Children Eligibility | Any Dependent Child under age 26. No age limit if disabled. |
Office Visits and Professional Services
| Service | Western Health Advantage Deductible First HDHP |
|---|---|
| Physician & Specialist | $20 copay after deductible |
| Preventive Care Birth to Age 18 | No Charge, no deductible |
| Preventive Care Adult Routine Care | No Charge, no deductible |
| Preventive Care Adult Routine OB/GYN | No Charge, no deductible |
| Diagnostic Lab and X-Ray | No charge after deductible |
| Physical Therapy
(Medically necessary treatment only) | $20 copay after deductible |
| Chiropractic and Acupuncture | No charge after deductible |
| Mental Health & Substance Use Disorder
(Outpatient) | $20 copay after deductible |
Surgical and Hospital Services
| Service | Western 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 Health | No charge after deductible up to 100 days per year |
Prescription Drugs
| Service | Western 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 Order | No |
| Mandatory Generic Program | Yes |