Page 14 - 2018 Carlstar Benefit Guide

14 BENEFITS ENROLLMENT • 2018

Medical Benefits Summary

Cigna
HSA—Silver Plan
PPO Out-of-Network
Employee Eligibility All active, full-time employees working a minimum of 30 hours per week
Lifetime Maximum Unlimited
Calendar Year Deductible Non-Embedded
Employee Only $1,500 $3,000
Family $3,000 $6,000
Employer Seeding
Employee Only Up to $750
Family Up to $1,500
Out-of-Pocket Maximum Includes Deductible, Embedded
Employee Only $3,000 Unlimited
Family $6,000 Unlimited
Physician Ofice Visits
Primary Care 80% after deductible 60% after deductible
Specialist 80% after deductible 60% after deductible
Urgent Care 80% after deductible
Wellness/Preventive 100% no cost share 60% after deductible
Lab Services
Physician Ofice 80% after deductible 60% after deductible
Outpatient Facility 80% after deductible 60% after deductible
Outpatient Hospital 80% after deductible 60% after deductible
X-Ray/Radiology Services
Physician Ofice 80% after deductible 60% after deductible
Outpatient Facility 80% after deductible 60% after deductible
Outpatient Hospital 80% after deductible 60% after deductible