Page 4 - 2022 Fantasea Benefit Guide English_Spanish

Medical Coverage
The Company offers a choice of medical plan options with Cigna; 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.

Plan 1 - $ Plan 2 - $$ Plan 3 - $$$
Plan Provisions Out-of- Out-of- Out-of-
In- Network In- Network In- Network
Network Network Network
Cigna Network HSA In-Network Base In-Network Buy-Up
Deductible Single/Family $2,500/$5,000 $1,500/$3,000
(Ind/Family) $2,000/$4,000
Out-of-Pocket
Max. (Includes $4,500/$9,000 $5,000/$10,000 $4,000/$8,000
Deductible) Aggregate
(Ind/Family)
Coinsurance 80% 70% 70%
(Plan pays)

Preventive Care Not Covered Not Covered Not Covered
100% 100% 100%
Primary Care $20, after ded $30 Copay $30 Copay
Physician

Specialist $40, after ded $50 Copay $50 Copay
Inpatient
Hospital 80%, after ded
Services 70% after ded 70%, after ded
Outpatient 80%, after ded
Hospital Services
Urgent Care $50 Copay $50 Copay
80% after ded
Emergency
Room Care 100% after $100 Copay and ded 100% after $100 Copay and ded 100% after $100 Copay and ded
Retail
Prescriptions
30-day supply 30-day supply
(30- day supply) 30-day supply $15 copay $15 Copay
Generic Plan pays 60% after ded $50 copay $50 Copay
$75 copay
Preferred $75 Copay
Non-preferred Not
Mail Order Not Covered Covered
Prescriptions
(90-day 90-day supply 90-day supply 90-day supply
supply)
Generic Plan pays 60% after ded 2.5x Retail 2.5x Retail
Preferred
Non-preferred

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