Page 8 - 2019 Sertek Enrollment Guide

2019 BENEFITS ENROLLMENT

OAP Plan
In-Network Out-of-Network
Plan Maximum
Per Lifetime Unlimited
Deductible per Calendar Year—Embedded
Per Individual $3,000 $7,500
Per Family $9,000 $15,000

Maximum Out-of-Pocket Exposure per Calendar Year (Includes Deductible)
Per Individual $6,000 $15,000
Per Family $12,000 $30,000
Coinsurance 100% after deductible 50% after deductible
Covered Services
Hospital Services
Inpatient 100% after deductible 50% after deductible
Outpatient 100% after deductible 50% after deductible
Emergency Room $250 copay $250 copay
Urgent Care Center $100 copay 50% after deductible
Physician Services
Office Visit PCP—$30 copay 50% after deductible
Specialist—$60 copay
Other Covered Services
Preventive Care 100% covered 50% after deductible
Telemedicine $30 copay N/A

Prescription Drug Benefit*

OAP Plan
Retail Pharmacy (30-Day Supply) Mail Order Pharmacy
(90-Day Supply)
Generic $10 copay $25 copay
Formulary Copay $30 copay $75 copay
Non-Formulary Copay $70 copay $175 copay
* All specialty medications must be filled through the CIGNA Specialty Pharmacy network; if you select a brand name drug when
a generic equivalent is available, the plan will only pay the cost of the generic drug; the plan will not cover medications for which
there is an equivalent over-the-counter alternative, all listed maintenance medications must be filled through home delivery or 90
Now network pharmacies.
Bi-Weekly Medical Contributions—Paid By You on a Pre-Tax Basis

$3,000 OAP Employee Premiums
Employee $42
Employee/Spouse $215
Employee/Child(ren) $184
Family $358

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