Page 9 - 2019 Benefit Guide Non-CA

PPO MEDICAL COVERAGE

CIGNA PPO (OAP) HSA PPO
COVERAGE
In-Network Out-of-Network In-Network Out-of-Network

Deductible $1,500 / $3,000 $2,000 / $4,000 $3,000 / $6,000 $6,000 / $12,000
Maximum Out-of-Pocket $4,500 / $9,000 $9,000 / $18,000 $5,000 / $10,000 $10,000 / $20,000
(Single/Family)
Physician Services
PCP Office Visits $40 copay 40% after deductible 20% after deductible 40% after deductible
Specialists Office Visits $40 copay 40% after deductible 20% after deductible 40% after deductible
Lab, X-ray (Basic) 20% after deductible 40% after deductible 20% after deductible 40% after deductible
Complex, Lab and 20% after deductible 40% after deductible 20% after deductible 40% after deductible
X-ray
Well Baby/Child Exam No copay 40% after deductible No copay 40% after deductible
Adult Physicals No copay Not covered No copay Not covered
Hospital Services
20% after deductible 40% after deductible
Room and Board 20% after deductible 40% after deductible
plus $500 copay plus $1,000 copay
Outpatient Surgery 20% after deductible 40% after deductible 20% after deductible 40% after deductible
Emergency Care
Copayment $250 copay $250 copay 20% after deductible 20% after deductible
(waived if admitted)
Urgent Care $125 copay 40% after deductible 20% after deductible 40% after deductible
Ambulance - 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Emergency only
Durable Medical 20% after deductible 40% after deductible 20% after deductible 40% after deductible
Equipment
Prescription Drugs
Tier 1 - $15 copay 50% coinsurance $15 copay after 50% coinsurance
Generic Formulary deductible
Tier 2 - $30 copay 50% coinsurance $30 copay after 50% coinsurance
Brand Name Formulary deductible
$45 copay after
Tier 3 - Non Formulary $45 copay 50% coinsurance 50% coinsurance
deductible
Tier 4 - $100 copay Not covered $100 copay after Not covered
Specialty/Injectable deductible
Mail Order: 2x copay Not covered 2x copay Not covered
Up to 90-day supply Tier 1, 2 and 3 Tier 1, 2 and 3

What is a PPO?
The PPO OAP plan give you the freedom of choice and greater flexibility.
You are not required to choose a primary care physician and do not need a referral to see a specialist.
The PPO offers a large network of contracting doctors and hospitals to choose from when care is needed.
When a contracting network provider is used, the care is considered “in-network.”

How does a PPO with an HSA work?
You will have to satisfy your deductible before the plan will share in the cost for services except on in-network
preventive care services.
This plan makes you eligible to contribute pre-tax dollars to a Health Savings Account (HSA) (See page 13 for
eligibility and plan details.).

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