Page 9 - Dawson 2021 New Hire Guide

2021 Benefits 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 $5,500 $16,500 $3,000 $9,000 $5,000 $10,000
Family $11,000 $33,000 $6,000 $18,000 $10,000 $20,000
Physician Oice Visits
Preventive Care Covered at 100% Deductible, then Covered at 100% Deductible, then Covered at 100% Deductible, then
40% coinsurance 40% coinsurance 40% coinsurance
Primary Care $35 copay Deductible, then $25 copay Deductible, then Deductible, then Deductible, then
Visit 40% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Specialist Visit $50 copay Deductible, then $40 copay Deductible, then Deductible, then Deductible, then
40% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Telemedicine $35 copay Not covered $25 copay Not covered $55 applied to the Not covered
deductible
Urgent Care $55 copay Deductible, then $55 copay Deductible, then Deductible, then Deductible, then
40% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Hospital Services
Inpatient Deductible, then Deductible, then Deductible, then Deductible, then Deductible, then Deductible, then
20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Outpatient Deductible, then Deductible, then Deductible, then Deductible, then Deductible, then Deductible, then
20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Emergency $250 copay $250 copay $250 copay $250 copay Deductible, then Deductible, then
Room 20% coinsurance 40% coinsurance
Prescription Drugs
Please note: for the HDHP qualiied plan, all non-preventive, non-generic prescription drug Drugs on Cigna's Preventive Generic
expenses are subject to the medical deductible. Once you meet your deductible, copays, or drug list are covered at 100%, no
coinsurance will apply. deductible.
Retail (per 30-day supply)
Generic* $10 copay $10 copay Deductible, then $10 copay
Preferred Brand $35 copay $35 copay Deductible, then $35 copay
Formulary
Non-Preferred $60 copay $60 copay Deductible, then $60 copay
Brand Formulary
Specialty 25% up to a maximum of $250 25% up to a maximum of $250 Deductible, then 25% up to a
maximum of $250
Mail Order—Retail and Home Delivery (per 90-day supply)
Generic* $20 copay $20 copay Deductible, then $20 copay
Preferred Brand $70 copay $70 copay Deductible, then $70 copay
Formulary
Non-Preferred $120 copay $120 copay Deductible, then $120 copay
Brand Formulary
* If you select a brand name drug when a generic equivalent is available, the plan will only pay the cost of the generic drug unless your physician
indicates “Dispense as Written” on the prescription.

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.

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