Page 10 - 2020 Dawson New Hire Guide

US Mainland—Medical Plan Details

This plan is only available to U.S. mainland employees.

Cigna Open Access Plus Cigna Open Access Plus Cigna Open Access Plus
Base—$2,000 PPO Choice—$1,000 PPO HDHP 1—$3,000 HDHP
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Embedded Embedded Embedded
Individual $2,000 $4,000 $1,000 $3,000 $3,000 $6,000
Family $4,000 $12,000 $2,000 $6,000 $6,000 $12,000
Out-of-Pocket Maximum (includes deductible)
Individual $6,350 $16,000 $3,000 $9,000 $5,000 $10,000
Family $12,700 $48,000 $6,000 $18,000 $10,000 $20,000
Physician Oice Visits
Preventive Care Covered at Deductible; Covered at Deductible; Covered at 100% Deductible; 40%
100% 50% 100% 30% coinsurance
coinsurance coinsurance
Primary Care Visit $35 copay Deductible; $25 copay Deductible; Deductible; 20% Deductible; 40%
50% 30% coinsurance coinsurance
coinsurance coinsurance
Specialist Visit $50 copay Deductible; $40 copay Deductible; Deductible; 20% Deductible; 40%
50% 30% coinsurance coinsurance
coinsurance coinsurance
Telemedicine $35 copay Not covered $25 copay Not covered $55 copay Not covered
that applies to
deductible; 20%
coinsurance
Urgent Care $75 copay Deductible; $75 copay Deductible; Deductible; 20% Deductible; 40%
50% 30% coinsurance coinsurance
coinsurance coinsurance
Hospital Services
Inpatient Deductible; Deductible; Deductible; Deductible; Deductible; 20% Deductible; 40%
30% 50% 20% 40% coinsurance coinsurance
coinsurance coinsurance coinsurance coinsurance
Outpatient Deductible; Deductible; Deductible; Deductible; Deductible; 20% Deductible; 40%
30% 50% 20% 40% coinsurance coinsurance
coinsurance coinsurance coinsurance coinsurance
Emergency Room $250 copay $250 copay $250 copay $250 copay Deductible; 20% Deductible; 40%
coinsurance coinsurance

10 2020 Benefits Guide