Page 5 - TVS 2021 Benefits Guide

2021
TVS SCS NA Benefits Enrollment

Cigna Plan 1—HDHP/HSA Cigna Plan 2—PPO
In-Network Out-of-Network In-Network Out-of-Network
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited
Calendar Year Deductible
Individual $2,200 $4,500 $1,500 $3,000
Family $4,400 $9,000 $3,000* $6,000*
* Once the family deductible is met, all family members will be considered having met their deductible for the remainder of the calendar year . No
one family member may contribute more than the individual deductible amount to the family deductible .
Coinsurance
0% 30% 20% 40%
Out-of-Pocket Maximum Includes Deductible Includes Deductible Includes Deductible Includes Deductible
Individual $2,200 $10,000 $3,500 $7,000
Family $4,400 $20,000 $7,000* $14,000*
* Once the family maximum out-of-pocket limit is met, all family members will be considered having met their maximum out-of-pocket limit for
the remainder of the calendar year . No one family member may contribute more than the individual maximum out-of-pocket limit amount to
the family maximum out-of-pocket limit . The out-of-pocket limit includes all copays, deductibles, and coinsurance .
Physician Oice Visits
Primary Care Covered 100% 30% after deductible $40 copay 30% after deductible
after deductible
Specialist Covered 100% 30% after deductible $65 copay 30% after deductible
after deductible
Urgent Care Covered 100% 30% after deductible $50 copay; 30% after deductible
after deductible deductible waived
Non-Urgent Use of Not covered Not covered Not covered Not covered
Urgent Care Provider
Wellness/Preventive
Routine Adult Physical Exams/ Covered 100%, 30% after deductible $0 copay; 30% after deductible
Immunizations no deductible deductible waived
Well Child Exams/ Covered 100%, 30% after deductible $0 copay; 30% after deductible
Immunizations no deductible deductible waived
Routine Gynecological Exams Covered 100%, 30% after deductible $0 copay; 30% after deductible
no deductible deductible waived
Routine Mammograms Covered 100%, 30% after deductible $0 copay; 30% after deductible
no deductible deductible waived
Women’s Health Covered 100%, 30% after deductible $0 copay; 30% after deductible
no deductible deductible waived
Routine Digital Rectal Exam/ Covered 100%, 30% after deductible $0 copay; 30% after deductible
Prostate-Speciic Antigen Test no deductible deductible waived
(for covered males age 40
and over)
Routine or Preventive Colorectal Covered 100%, 30% after deductible $0 copay; 30% after deductible
Cancer Screening no deductible deductible waived
(for all members age 50
and over)
Routine Eye Exams at Covered 100%, 30% after deductible $0 copay; 30% after deductible
Specialist (1 routine exam per no deductible deductible waived
12 months)
Diagnostic Procedures
Outpatient Diagnostic Covered 100% 30% after deductible 20% after deductible 40% after deductible
Laboratory after deductible
Outpatient X-ray (except Covered 100% 30% after deductible 20% after deductible 40% after deductible
complex imaging services) after deductible
MRI, MRA, PET, and CT Scans Covered 100% 30% after deductible 20% after deductible 40% after deductible
after deductible

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