Page 6 - Cornerstone Systems New Hire Guide

Beneit Guide

Schedule of Cigna options for the 2014-2015 plan year
Plan Components HDHP
In-Network Out-of-Network
Annual Deductible—Collective * Single $1,700 $3,500
(January-December) Family $3,500 $7,000

Coinsurance (plan pays) 80% 60%
Out-of-Pocket Maximum Single $4,000 $12,000
(includes deductibles) Family $8,000 $24,000

Maximum Lifetime Policy Beneit Unlimited Unlimited
Providers
Physician Ofice Visits 80% after deductible 60% after deductible
Specialist Ofice Visits 80% after deductible 60% after deductible
Preventive Services: (includes immunizations, annual physicals, 100% 100%
mammogram, pap smear, prostate exams, well-woman/man
exams)
Facilities
Hospital Services 80% after deductible 60% after deductible
Urgent Care Services 80% after deductible 60% after deductible
Emergency Room 80% after deductible 60% after deductible
Inpatient Services Facility charges 80% after deductible 60% after deductible
Mental Health and Substance Abuse (in-network prior 80% after deductible 60% after deductible
authorization required by United Behavioral Health)
Other Services
Outpatient Surgery 80% after deductible 60% after deductible
Outpatient diagnostic services—lab, x-rays, scans, and MRIs 80% after deductible 60% after deductible
Durable Medical Equipment 80% after deductible 60% after deductible
Home Healthcare—limited to 60 visits per calendar year 80% after deductible 60% after deductible
Skilled Nursing Facility—limited to 60 days per calendar year 80% after deductible 60% after deductible
Prescription Drugs
Retail Pharmacy (30-day supply)
Generic 80% after deductible 60% after deductible
Preferred Brand Name 80% after deductible 60% after deductible
Non Preferred Brand Name 80% after deductible 60% after deductible
Specialty Pharmacy 80% after deductible 60% after deductible

* Collective Deductible: Claims are covered under the coinsurance once the family deductible is met by any combination of family members;
individual deductibles do not apply.

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