Page 17 - 2018 Capgemini Enrollment
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Medical Plan Comparison Chart What’s an out-of-
pocket maximum?
Premier Open Access Plus Basic Open Access Plus
Covered Health Services In-Network Out-of-Network 1 In-Network Out-of-Network 1 The Medical Plan’s
out-of-pocket maximum
Office Visit Co-pays N/A N/A is the total amount
Wellness $0 $0 you pay out of pocket
Primary Care Physician $20 $20 (including deductibles,
Specialist $30 $30 co-pays and co-insurance)
TeleHealth Visit $20 $20 in one plan year before
the plan pays 100% of
Medical Deductible
You Only $300 $600 $600 $1,200 eligible expenses.
You + Spouse/Domestic Partner $600 $1,200 $1,200 $2,400
You + Child(ren) $600 $1,200 $1,200 $2,400 Save time and money
You + Family $600 $1,200 $1,200 $2,400 with TeleHealth
Connection.
Professional Services and
Hospital Services (Co-insurance) Cigna’s TeleHealth
Inpatient Care 85% after deductible 50% after deductible 2 75% after deductible 50% after deductible 2 Connection ofers two
Outpatient Care 85% after deductible 50% after deductible 2 75% after deductible 50% after deductible 2 services, Amwell and
MDLIVE, that give you
Annual Out-of-Pocket 24/7/365 access to a
Maximum doctor through a phone
You Only $3,150 $4,725 $4,500 $7,500 call or web chat for a $20
You + Spouse/Domestic Partner $6,300 $9,450 $9,000 $15,000 co-pay. You can use
You + Child(ren) $6,300 $9,450 $9,000 $15,000 Amwell and MDLIVE for
You + Family $6,300 $9,450 $9,000 $15,000 routine illnesses like
Lifetime Maximum Benefit 3 Unlimited Unlimited allergies, ear infections
and more. For more
Emergency Room Co-pay $100 (waived if admitted) $100 (waived if admitted) information, go to www.
amwellforcigna.com or
Urgent Care Co-pay $50 $50 www.mdliveforcigna.
com .
1 Out-of-network benefits will be based on maximum reimbursable costs as determined by Cigna. Continued on next page
2 There is a 20% penalty for failure to pre-certify an out-of-network hospital confinement.
3 Certain limitations apply to the Lifetime Maximum Benefit. Please see the Summary Plan Description for details.
Co-pays are not subject to deductible. The deductible must be met before co-insurance applies. Deductibles are met for the plan year when
(a) a covered member satisfies the individual deductible maximum or (b) any combination of covered members satisfies the family deductible
maximum. Out-of-pocket limits are met for the plan year when (a) a covered member satisfies the individual out-of-pocket maximum or
(b) any combination of covered members satisfies the family out-of-pocket maximum.
CAPGEMINI 2018 BENEFITS GUIDE 14
pocket maximum?
Premier Open Access Plus Basic Open Access Plus
Covered Health Services In-Network Out-of-Network 1 In-Network Out-of-Network 1 The Medical Plan’s
out-of-pocket maximum
Office Visit Co-pays N/A N/A is the total amount
Wellness $0 $0 you pay out of pocket
Primary Care Physician $20 $20 (including deductibles,
Specialist $30 $30 co-pays and co-insurance)
TeleHealth Visit $20 $20 in one plan year before
the plan pays 100% of
Medical Deductible
You Only $300 $600 $600 $1,200 eligible expenses.
You + Spouse/Domestic Partner $600 $1,200 $1,200 $2,400
You + Child(ren) $600 $1,200 $1,200 $2,400 Save time and money
You + Family $600 $1,200 $1,200 $2,400 with TeleHealth
Connection.
Professional Services and
Hospital Services (Co-insurance) Cigna’s TeleHealth
Inpatient Care 85% after deductible 50% after deductible 2 75% after deductible 50% after deductible 2 Connection ofers two
Outpatient Care 85% after deductible 50% after deductible 2 75% after deductible 50% after deductible 2 services, Amwell and
MDLIVE, that give you
Annual Out-of-Pocket 24/7/365 access to a
Maximum doctor through a phone
You Only $3,150 $4,725 $4,500 $7,500 call or web chat for a $20
You + Spouse/Domestic Partner $6,300 $9,450 $9,000 $15,000 co-pay. You can use
You + Child(ren) $6,300 $9,450 $9,000 $15,000 Amwell and MDLIVE for
You + Family $6,300 $9,450 $9,000 $15,000 routine illnesses like
Lifetime Maximum Benefit 3 Unlimited Unlimited allergies, ear infections
and more. For more
Emergency Room Co-pay $100 (waived if admitted) $100 (waived if admitted) information, go to www.
amwellforcigna.com or
Urgent Care Co-pay $50 $50 www.mdliveforcigna.
com .
1 Out-of-network benefits will be based on maximum reimbursable costs as determined by Cigna. Continued on next page
2 There is a 20% penalty for failure to pre-certify an out-of-network hospital confinement.
3 Certain limitations apply to the Lifetime Maximum Benefit. Please see the Summary Plan Description for details.
Co-pays are not subject to deductible. The deductible must be met before co-insurance applies. Deductibles are met for the plan year when
(a) a covered member satisfies the individual deductible maximum or (b) any combination of covered members satisfies the family deductible
maximum. Out-of-pocket limits are met for the plan year when (a) a covered member satisfies the individual out-of-pocket maximum or
(b) any combination of covered members satisfies the family out-of-pocket maximum.
CAPGEMINI 2018 BENEFITS GUIDE 14
