Page 6 - SIH 2022 Re-Enrollment Guide
P. 6
MEDICAL PLAN DESIGN
For SIH full-time employees who work 72 hours or more per pay period, part-time employees who work 40-
71 hours per pay period, and ineligible part-time employees or PRN employees who average 30 hours per
week of actual time worked after a 12-month look-back.
QHP* Collaborative Partner Cigna Network Out-of-Network
Network Providers Network Providers Providers Providers
Deductible (single/family) $500/$1,500 $1,500/$4,500 $2,500/$7,500 $4,000/$12,000
Out-of-Pocket Maximum (Single/Family)
Medical Out-of-Pocket Maximum (single/ $2,500/$5,000 $3,500/$7,000 $4,500/$9,000 Unlimited
family)
Pharmacy Out-of-Pocket maximum $2,000/$4,000 $2,000/$4,000 $2,000/$4,000 $2,000/$4,000
(single/family)
Copays/Coinsurance
Hospital Inpatient 5% after ded. 20% after ded. 30% after ded. 50% after ded.
Outpatient Hospital Surgery 5% after ded. 20% after ded. 30% after ded. 50% after ded.
Other Hospital Outpatient 5% after ded. 20% after ded. 30% after ded. 50% after ded.
Hospice 0% no charge 0% no charge 0% no charge 50% after ded.
Home Healthcare 5% after ded. 10% after ded. 30% after ded. 50% after ded.
Rehabilitative Therapy (up to 60 combined $20 copay $30 copay 30% after ded. 50% after ded.
visits per year)
PCP Oice Visit $20 copay $30 copay $40 copay 50% after ded.
Specialist Oice Visit $30 copay $40 copay $50 copay 50% after ded.
Other Physician Services 5% after ded. 20% after ded. 30% after ded. 50% after ded.
(lab, diagnostic)
Outpatient Labs, Imaging, and Diagnostic 5% (ded. waived) 20% after ded. 30% after ded. 50% after ded.
Tests at SIH Facilities
Preventive Care 0% no charge 0% no charge 0% no charge 50% after ded.
Durable Medical Equipment (DME)** 5% after ded.** Not applicable 30% after ded. 50% after ded.
Walk-In Clinics/Prompt Care*** $20 copay $30 copay $40 copay 50% after ded.
Urgent Care $50 copay $50 copay $50 copay $50 copay
Emergency Room (true emergency) $250 copay $250 copay $250 copay $250 copay
Other ER Care 20% after ded. 30% after ded. 30% after ded. 50% after ded.
(not true emergency)
Spinal Manipulation 50% after ded. 50% after ded. 50% after ded. 50% after ded.
($500 maximum)
50% coinsurance ded.
Outpatient Mental Health Services $20 $20 $20 waived, not subject to
MEE
This table represents employee cost.
* To ind QHP providers, go to askallegiance.com/SIH.
** DME goods fulilled by EviCore and our Client Speciic Network follow the QHP rate; EviCore can be reached at 855.999.1052; see deinition of
DME on the following page.
*** What you will pay for SIH prompt care
6
For SIH full-time employees who work 72 hours or more per pay period, part-time employees who work 40-
71 hours per pay period, and ineligible part-time employees or PRN employees who average 30 hours per
week of actual time worked after a 12-month look-back.
QHP* Collaborative Partner Cigna Network Out-of-Network
Network Providers Network Providers Providers Providers
Deductible (single/family) $500/$1,500 $1,500/$4,500 $2,500/$7,500 $4,000/$12,000
Out-of-Pocket Maximum (Single/Family)
Medical Out-of-Pocket Maximum (single/ $2,500/$5,000 $3,500/$7,000 $4,500/$9,000 Unlimited
family)
Pharmacy Out-of-Pocket maximum $2,000/$4,000 $2,000/$4,000 $2,000/$4,000 $2,000/$4,000
(single/family)
Copays/Coinsurance
Hospital Inpatient 5% after ded. 20% after ded. 30% after ded. 50% after ded.
Outpatient Hospital Surgery 5% after ded. 20% after ded. 30% after ded. 50% after ded.
Other Hospital Outpatient 5% after ded. 20% after ded. 30% after ded. 50% after ded.
Hospice 0% no charge 0% no charge 0% no charge 50% after ded.
Home Healthcare 5% after ded. 10% after ded. 30% after ded. 50% after ded.
Rehabilitative Therapy (up to 60 combined $20 copay $30 copay 30% after ded. 50% after ded.
visits per year)
PCP Oice Visit $20 copay $30 copay $40 copay 50% after ded.
Specialist Oice Visit $30 copay $40 copay $50 copay 50% after ded.
Other Physician Services 5% after ded. 20% after ded. 30% after ded. 50% after ded.
(lab, diagnostic)
Outpatient Labs, Imaging, and Diagnostic 5% (ded. waived) 20% after ded. 30% after ded. 50% after ded.
Tests at SIH Facilities
Preventive Care 0% no charge 0% no charge 0% no charge 50% after ded.
Durable Medical Equipment (DME)** 5% after ded.** Not applicable 30% after ded. 50% after ded.
Walk-In Clinics/Prompt Care*** $20 copay $30 copay $40 copay 50% after ded.
Urgent Care $50 copay $50 copay $50 copay $50 copay
Emergency Room (true emergency) $250 copay $250 copay $250 copay $250 copay
Other ER Care 20% after ded. 30% after ded. 30% after ded. 50% after ded.
(not true emergency)
Spinal Manipulation 50% after ded. 50% after ded. 50% after ded. 50% after ded.
($500 maximum)
50% coinsurance ded.
Outpatient Mental Health Services $20 $20 $20 waived, not subject to
MEE
This table represents employee cost.
* To ind QHP providers, go to askallegiance.com/SIH.
** DME goods fulilled by EviCore and our Client Speciic Network follow the QHP rate; EviCore can be reached at 855.999.1052; see deinition of
DME on the following page.
*** What you will pay for SIH prompt care
6
