Page 8 - 2022 Clarins Benefit Guide

YOUR BENEFITS GUIDE 2022

Medical Coverage

Clarins offers a choice of three medical plan options; you choose the plan that meets your
needs and those of your family. Each plan includes comprehensive health care benefits,
including free preventive care services and coverage for prescription drugs.

Medical and Prescription Plans
In-Network Only
Plan Provisions Open Access Plus Health Savings Account
Open Access Plus
In-Network Out-of-Network* In-Network Only In-Network Out-of-Network*
$600 / $1,800 $2,000 / $6,000 $800 / $2,400 $1,500 / $4,500 $3,000 / $9,000
Deductible
Single / Family If you elect family coverage, deductible expenses for each covered family If you elect family coverage, the entire family
member are capped at the single deductible amount deductible must be satisfied prior to plan paying
benefits
Health Savings Account
Fund (Clarins Deposit) N/A N/A $500 / $1,000
Plan Pays 80% / Plan Pays 60% / Plan Pays 70% / Plan Pays 80% / Plan Pays 60% /
Coinsurance
You Pay 20% You Pay 40% You Pay 30% You Pay 20% You Pay 40%
$3,400 / $10,200 $4,000 / $12,000 $3,000 / $9,000 $3,500 / $10,500 $7,000 / $21,000
Out-of- Pocket Maximum
Single / Family
(Includes deductible, If you elect family If you elect family
coinsurance, and copays) If you elect family coverage, annual expenses for each covered family coverage, no individual coverage, no individual
member are capped at the single out-of-pocket maximum will exceed $7,050 in will exceed $7,000 in
annual expenses annual expenses
Preventive Care Covered at 100% 60% after deductible Covered at 100% Covered at 100% 60% after deductible
Office Visits $20 / $40 copay 60% after deductible $20 / $40 copay 80% after deductible 60% after deductible
Primary / Specialist
$200 copay, then 80% $300 copay, then 70%
Inpatient Hospital 60% after deductible 80% after deductible 60% after deductible
after deductible after deductible
Emergency room $200 copay, then 80% $200 copay, then 70% 80% after deductible
Rx (Retail) 30 day supply $5 $5
Generic Copay
Brand Preferred Coinsurance 30% coinsurance; 30% coinsurance;
Minimum / Maximum Copay $40 / $85 $40 / $85
Brand Non- Preferred 40% coinsurance; 40% coinsurance; 80% after deductible
Coinsurance $65 / $110 $65 / $110
Minimum / Maximum Copay
Rx (Mail Order) 90 day supply $13
Generic Copay $13 Not Covered Not Covered
Preventive Generic Copay $0 $0
Brand Preferred Coinsurance 30% coinsurance; 30% coinsurance;
Minimum / Maximum Copay $70 / $160 $70 / $160 80% after deductible
Brand Non- Preferred 40% coinsurance; 40% coinsurance;
Coinsurance $120 / $210 $120 / $210
Minimum / Maximum Copay

Note: This is a summary of coverage only; the summary plan descriptions govern and contain exclusions and
limitations that are not shown here.
*In-network services are based on negotiated charges; out-of-network services are based on 300% of Medicare and
may result in providers balance billing members for charges beyond Cigna’s allowable reimbursement.

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