Page 15 - 2018 Carlstar Benefit Guide

BENEFITS ENROLLMENT • 201815

Medical Beneits Summary (continued)

Cigna
HSA—Silver Plan
PPO Out-of-Network
Hospital Services
Inpatient 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible
Emergency Room 80% after deductible
Mental Health/Substance Abuse
Inpatient 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible
Ofice Visits 80% after deductible 60% after deductible
Chiropractic Care
80% after deductible 60% after deductible
Limitations 20 days
Prescription Drugs
Retail—Supply Limit 30 Days
Tier 1 80% after deductible 60% after deductible
Tier 2 80% after deductible 60% after deductible
Tier 3 80% after deductible 60% after deductible
Mail Order—Supply Limit 90 Days
Tier 1 80% after deductible Not covered
Tier 2 80% after deductible Not covered
Tier 3 80% after deductible Not covered