Page 6 - Ideal Option 2020 New Hire Guide
P. 6
Medical Plan Details
Cigna Choice Fund
PPO HDHP
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible*
Individual $1,500 $2,800
Family $3,000 $5,600
Out-of-Pocket Max
Individual $4,000 $20,000 $4,000 $20,000
Family $8,000 $40,000 $8,000 $40,000
Physician Oice Visits
Preventive Care Covered 100% 60% after deductible Covered 100% 60% after deductible
Primary Care Visit $30 copay 60% after deductible 80% after deductible 60% after deductible
Specialist Visit $50 copay 60% after deductible 80% after deductible 60% after deductible
Telemedicine $30 copay Not covered $55 applies to your Not covered
deductible
Urgent Care $75 copay 60% after deductible 80% after deductible 60% after deductible
Hospital Services
Inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Emergency Room $250 copay + 80% $250 copay + 80% 80% after deductible 80% after deductible
after deductible after deductible
Prescription Drugs
Retail — 30 Day Supply
Preventive Drugs Same as below Not covered 100%, deductible waived Not covered
Generic $10 copay Not covered 80% after deductible Not covered
Preferred Brand Formulary $35 copay Not covered 80% after deductible Not covered
Non-Preferred Brand Formulary $75 copay Not covered 80% after deductible Not covered
Specialty Drugs $200 copay Not covered 80% after deductible Not covered
Mail Order — 90 Day Supply
Preventive Drugs Same as below Not covered 100%, deductible waived Not covered
Generic $30 copay Not covered 80% after deductible Not covered
Preferred Brand Formulary $105 copay Not covered 80% after deductible Not covered
Non-Preferred Brand Formulary $225 copay Not covered 80% after deductible Not covered
Please note: For those enrolled in the Choice Fund HDHP plan certain preventive medications are available at no cost to you (see
preventive drug list for more details).
* Both medical plans have an embedded deductible and out-of-pocket maximum which means that if an individual meets the
$2,800 deductible and $4,000 out-of-pocket (OOP) maximum, the individual will receive 100% coverage for the remainder of
the year. The entire family deductible nor OOP maximum is required to be met for an individual with family coverage.
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In
the event there is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your
SPD will prevail.
Pre-Certification Requirements
Additional pre-certiication requirements must be met for high tech imaging and several other medical procedures. All pre-
certiication requirements will be taken care of for you as long as you seek care from an in-network Cigna provider.
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Cigna Choice Fund
PPO HDHP
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible*
Individual $1,500 $2,800
Family $3,000 $5,600
Out-of-Pocket Max
Individual $4,000 $20,000 $4,000 $20,000
Family $8,000 $40,000 $8,000 $40,000
Physician Oice Visits
Preventive Care Covered 100% 60% after deductible Covered 100% 60% after deductible
Primary Care Visit $30 copay 60% after deductible 80% after deductible 60% after deductible
Specialist Visit $50 copay 60% after deductible 80% after deductible 60% after deductible
Telemedicine $30 copay Not covered $55 applies to your Not covered
deductible
Urgent Care $75 copay 60% after deductible 80% after deductible 60% after deductible
Hospital Services
Inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Emergency Room $250 copay + 80% $250 copay + 80% 80% after deductible 80% after deductible
after deductible after deductible
Prescription Drugs
Retail — 30 Day Supply
Preventive Drugs Same as below Not covered 100%, deductible waived Not covered
Generic $10 copay Not covered 80% after deductible Not covered
Preferred Brand Formulary $35 copay Not covered 80% after deductible Not covered
Non-Preferred Brand Formulary $75 copay Not covered 80% after deductible Not covered
Specialty Drugs $200 copay Not covered 80% after deductible Not covered
Mail Order — 90 Day Supply
Preventive Drugs Same as below Not covered 100%, deductible waived Not covered
Generic $30 copay Not covered 80% after deductible Not covered
Preferred Brand Formulary $105 copay Not covered 80% after deductible Not covered
Non-Preferred Brand Formulary $225 copay Not covered 80% after deductible Not covered
Please note: For those enrolled in the Choice Fund HDHP plan certain preventive medications are available at no cost to you (see
preventive drug list for more details).
* Both medical plans have an embedded deductible and out-of-pocket maximum which means that if an individual meets the
$2,800 deductible and $4,000 out-of-pocket (OOP) maximum, the individual will receive 100% coverage for the remainder of
the year. The entire family deductible nor OOP maximum is required to be met for an individual with family coverage.
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In
the event there is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your
SPD will prevail.
Pre-Certification Requirements
Additional pre-certiication requirements must be met for high tech imaging and several other medical procedures. All pre-
certiication requirements will be taken care of for you as long as you seek care from an in-network Cigna provider.
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