Page 5 - 2015 Enrollment Guide
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Medical Benefits
CIGNA CHOICE FUND CIGNA CHOICE FUND KAISER HMO
OPEN ACCESS PLUS HRA OPEN ACCESS PLUS HSA (For Associates in
(Health Reimbursement Arrangement) (Health Savings Account) GA/VA/DC/MD)
PLAN FEATURE IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK ONLY
BENEFITS
BENEFITS
BENEFITS
BENEFITS
BENEFITS
Post Contribution to
HRA & HSA on 1/1/2015 Individual $250 Individual $250
(Amount is reduced by 50% Family $500 Family $500 N/A
if enrollment in the plan is
effective on or after July 1)
Annual Deductible*
Individual $1,250 $2,500 $1,750 $3,500 $500
Family $2,500 $5,000 $3,500 $7,000 $1,000
Coinsurance Levels 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible
(You pay % shown)
Out-of-Pocket
Maximums* (Includes
deductible, coinsurance, &
copays)
Individual $3,750 $7,500 $3,750 $7,500 $2,500 Comparing Your 2015 Medical Plan Options
Family $7,500 $15,000 $7,500 $15,000 $5,000
Preventive Care Covered at 100% Not covered Covered at 100% Not covered Covered at 100%
Office Visits
PCP $35 copay 50% after deductible 20% after deductible 50% after deductible $25 copay
Specialist $45 copay 50% after deductible 20% after deductible 50% after deductible $35 copay
In-network benefit In-network benefit
applies for an applies for an
Urgent Care $50 copay emergency medical 20% after deductible emergency medical $50 copay
condition; otherwise condition; otherwise
50% after deductible 50% after deductible
In-network benefit In-network benefit
applies for an
applies for an
Emergency Room $200 copay emergency medical 20% after deductible emergency medical $200 copay
(Waived if admitted) condition; otherwise condition; otherwise
50% after deductible 50% after deductible
*With the HRA and HMO plans, both the individual deductible and the family deductible may apply regardless of the tier in which you enroll. For
example, if you enroll one or more dependents in the HRA plan, the plan will start paying its portion of coinsurance for an individual once that
member of your family reaches the individual deductible. It will also start paying its portion of coinsurance for every member of your family once
the sum of all family members’ medical costs reaches the family deductible.
With the HSA plan, the individual deductible ONLY applies when you are enrolled in the “Employee” tier; and the family deductible ONLY applies
when you are enrolled in a tier OTHER than “Employee”. If you enroll one or more dependents, benefits are not paid until the family deductible is
reached.
Out-of-pocket maximums are treated similarly. For the HRA plan, both the individual and family out-of-pocket maximums apply if you have elected
to enroll one or more dependents; but in the HSA plan, the individual out-of-pocket maximum does not apply if you have elected to enroll one or
more dependents in the plan.
Medical Benefits
CIGNA CHOICE FUND CIGNA CHOICE FUND KAISER HMO
OPEN ACCESS PLUS HRA OPEN ACCESS PLUS HSA (For Associates in
(Health Reimbursement Arrangement) (Health Savings Account) GA/VA/DC/MD)
PLAN FEATURE IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK ONLY
BENEFITS
BENEFITS
BENEFITS
BENEFITS
BENEFITS
Post Contribution to
HRA & HSA on 1/1/2015 Individual $250 Individual $250
(Amount is reduced by 50% Family $500 Family $500 N/A
if enrollment in the plan is
effective on or after July 1)
Annual Deductible*
Individual $1,250 $2,500 $1,750 $3,500 $500
Family $2,500 $5,000 $3,500 $7,000 $1,000
Coinsurance Levels 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible
(You pay % shown)
Out-of-Pocket
Maximums* (Includes
deductible, coinsurance, &
copays)
Individual $3,750 $7,500 $3,750 $7,500 $2,500 Comparing Your 2015 Medical Plan Options
Family $7,500 $15,000 $7,500 $15,000 $5,000
Preventive Care Covered at 100% Not covered Covered at 100% Not covered Covered at 100%
Office Visits
PCP $35 copay 50% after deductible 20% after deductible 50% after deductible $25 copay
Specialist $45 copay 50% after deductible 20% after deductible 50% after deductible $35 copay
In-network benefit In-network benefit
applies for an applies for an
Urgent Care $50 copay emergency medical 20% after deductible emergency medical $50 copay
condition; otherwise condition; otherwise
50% after deductible 50% after deductible
In-network benefit In-network benefit
applies for an
applies for an
Emergency Room $200 copay emergency medical 20% after deductible emergency medical $200 copay
(Waived if admitted) condition; otherwise condition; otherwise
50% after deductible 50% after deductible
*With the HRA and HMO plans, both the individual deductible and the family deductible may apply regardless of the tier in which you enroll. For
example, if you enroll one or more dependents in the HRA plan, the plan will start paying its portion of coinsurance for an individual once that
member of your family reaches the individual deductible. It will also start paying its portion of coinsurance for every member of your family once
the sum of all family members’ medical costs reaches the family deductible.
With the HSA plan, the individual deductible ONLY applies when you are enrolled in the “Employee” tier; and the family deductible ONLY applies
when you are enrolled in a tier OTHER than “Employee”. If you enroll one or more dependents, benefits are not paid until the family deductible is
reached.
Out-of-pocket maximums are treated similarly. For the HRA plan, both the individual and family out-of-pocket maximums apply if you have elected
to enroll one or more dependents; but in the HSA plan, the individual out-of-pocket maximum does not apply if you have elected to enroll one or
more dependents in the plan.
