Western Health Advantage Hospital Services DHMO

Human Resources Benefits Unit 750

The Hospital Services DHMO plan requires you to live within the plan’s Northern California service area and to receive your non-emergency care from Western Health Advantage providers. You share in the cost of your care through copayments, coinsurance, and deductibles.

Most doctor’s office visits, radiology services, lab tests and prescriptions are available for copay or coinsurance amount, even before you have reached the calendar year deductible. Hospitalizations, in-patient, and out-patient surgeries are subject to the calendar year deductible before plan benefits will be paid.

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

Benefit Charts

Benefits Medical Plan Summary

Office and Professional Services

Surgical and Hospital Services

Prescription Drugs

Premium Rates

For Employees

Employee Semi Monthly Medical Plan Premiums
Extra-Help Semi Monthly Medical Plan Premiums

For Retirees

Non-Medicare Monthly Medical Plan Premiums

Medical Plan Summary

Plan Information	Western Health Advantage Hospital Services DHMO
Calendar Year Deductible	$1,500 Self-Only Enrollment $1,500 Any one member in a family of two or more $3,000 Family of two or more
Calendar Year Out of Pocket Maximum (Including Deductibles, Co-pays, and Coinsurance)	$4,000 Self-Only Enrollment $4,000 Any one member in a family of two or more $8,000 Family of two or more
Lifetime Maximum	None
Dependent Children Eligibility	Any Dependent child under age 26 Disabled: No age limit

Office Visit and Professional Services

Service	Western Health Advantage Hospital Services DHMO
Physician & Specialist Office Visits	$20 copay, no deductible
Preventive Care Adult Routine Care	No Charge, no deductible
Preventive Care Adult Routine Care OB/GYN	No Charge, no deductible
Diagnostic Imaging, Lab, and X-Ray	Diagnostic Lab: No charge, no deductible Diagnostic X-ray: No charge, no deductible
Physical Therapy (Medically necessary treatment only)	$20 co-pay, no deductible
Chiropractic and Acupuncture	Chiropractic: $15 Copay, no deductible up to 20 visits per year Acupuncture: $15 Copay, no deductible up to 20 visits per year
Mental Health & Substance Use Disorder (Outpatient)	$20 copay, no deductible

Surgical and Hospital Services

Service	Western Health Advantage Hospital Services DHMO
Inpatient Hospital and Physician Services	20% Coinsurance after deductible
Outpatient Surgery	20% Coinsurance after deductible
Maternity	20% Coinsurance after deductible
Emergency Room	20% Coinsurance after deductible
Ambulance	$150 per trip, no deductible
Mental Health & Substance Use Disorder (Inpatient)	20% Coinsurance after deductible
Skilled Nursing Facility	20% Coinsurance, no deductible Up to 100 days per benefit
Home Health	No Charge, no deductible Up to a 100 visits per year

Prescription Drugs

Service	Western Health Advantage Hospital Services DHMO
Generic or Tier 1	$10 copay up to a 30 day supply, no deductible
Formulary Brand or Tier 2	$30 copay up to a 30 day supply, no deductible
Non-Formulary Brand or Tier 3	$50 copay up to a 30 day supply, no deductible
Mail Order Benefit Generic or Tier 1	$20 copay up to a 100 day supply, no deductible
Mail Order Benefit Formulary Brand or Tier 2	$60 copay up to a 100 day supply, no deductible
Mail Order Benefit Non-Formulary Brand or Tier 3	$100 copay up to a 100 day supply, no deductible
Mandatory Mail Order	No
Mandatory Generic Program	Yes