Page 6 - 2015 Four Seasons Enrollment Guide
P. 6
Medical/Prescription Drug
Medical Insurance
We partner with Cigna to offer you medical insurance. Please note the HMO is a grandfathered plan and is only available to
employees hired prior to January 1, 2014. Employees hired on or after January 1, 2014 have the option to enroll in the HSA or
OAP. Employees hired prior to this date have the additional option of the HMO Plan.
You can obtain more detailed summary plan descriptions (SPDs) through the My Four Seasons Beneits website.
2015
HSA OAP HMO *
Deductible (Single/Family)
In-Network $1,500/$3,000 $1,500/$3,000 $300/$600
Out-of-Network $3,000/$6,000 $3,000/$6,000 N/A
Coinsurance
In-Network 80% 80% 85%
Out-of-Network 60% 60% N/A
Out-of-Pocket Max (includes deductible)
In-Network $3,500/$7,000 $3,500/$7,000 $3,000/$6,000
Out-of-Network $7,000/$14,000 $7,000/$14,000 N/A
Other
Primary Care Physician (In-Network) Ded/Coinsurance $30 $25
Specialist (In-Network) Ded/Coinsurance $60 $50
Emergency Room Ded/Coinsurance Ded/Coinsurance $200
Urgent Care Ded/Coinsurance Ded/Coinsurance $75
Rx (In-Network) $5/40/70/100x2 after ded.; once $5/40/70/ $5/$30/$60/$90x2
out-of-pocket max is met plan $100x2
pays 100%
* Not available to employees hired on or after January 1, 2014.
Important Deductible/Out-of-Pocket Notice for the
OAP and HSA Plans
Under the OAP Plan, if you are enrolled in the family plan, you, your spouse or
Scan this code to visit the
mycigna.com website children have to meet the individual deductible of $1,500 then the plan will
start reimbursing for the member, even though the $3,000 family deductible
has not been met. For example, if you incurred medical expenses of $2,000,
and the family deductible has not been met, Cigna will start reimbursing
your claims because you have met your deductible. Once two or more
family members in the plan meet the combined family deductible of $3,000
then the plan will start reimbursing for all family members, even though other
members of your family may not have met their individual deductible.
Under the HSA family plan, the individual deductible does not apply. For
Colour Elements example, if you incurred $2,000 in medical expenses, the plan will not
reimburse you until you, or, other members of your family have accumulated
medical expenses in excess of $3,000.
This applies to the Out-of-Pocket Maximum as well.
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BENEFITS
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Medical Insurance
We partner with Cigna to offer you medical insurance. Please note the HMO is a grandfathered plan and is only available to
employees hired prior to January 1, 2014. Employees hired on or after January 1, 2014 have the option to enroll in the HSA or
OAP. Employees hired prior to this date have the additional option of the HMO Plan.
You can obtain more detailed summary plan descriptions (SPDs) through the My Four Seasons Beneits website.
2015
HSA OAP HMO *
Deductible (Single/Family)
In-Network $1,500/$3,000 $1,500/$3,000 $300/$600
Out-of-Network $3,000/$6,000 $3,000/$6,000 N/A
Coinsurance
In-Network 80% 80% 85%
Out-of-Network 60% 60% N/A
Out-of-Pocket Max (includes deductible)
In-Network $3,500/$7,000 $3,500/$7,000 $3,000/$6,000
Out-of-Network $7,000/$14,000 $7,000/$14,000 N/A
Other
Primary Care Physician (In-Network) Ded/Coinsurance $30 $25
Specialist (In-Network) Ded/Coinsurance $60 $50
Emergency Room Ded/Coinsurance Ded/Coinsurance $200
Urgent Care Ded/Coinsurance Ded/Coinsurance $75
Rx (In-Network) $5/40/70/100x2 after ded.; once $5/40/70/ $5/$30/$60/$90x2
out-of-pocket max is met plan $100x2
pays 100%
* Not available to employees hired on or after January 1, 2014.
Important Deductible/Out-of-Pocket Notice for the
OAP and HSA Plans
Under the OAP Plan, if you are enrolled in the family plan, you, your spouse or
Scan this code to visit the
mycigna.com website children have to meet the individual deductible of $1,500 then the plan will
start reimbursing for the member, even though the $3,000 family deductible
has not been met. For example, if you incurred medical expenses of $2,000,
and the family deductible has not been met, Cigna will start reimbursing
your claims because you have met your deductible. Once two or more
family members in the plan meet the combined family deductible of $3,000
then the plan will start reimbursing for all family members, even though other
members of your family may not have met their individual deductible.
Under the HSA family plan, the individual deductible does not apply. For
Colour Elements example, if you incurred $2,000 in medical expenses, the plan will not
reimburse you until you, or, other members of your family have accumulated
medical expenses in excess of $3,000.
This applies to the Out-of-Pocket Maximum as well.
Logo & Logo Variations
My Four Seasons BENEFITS My Four Seasons 6
BENEFITS
Icon Image Elements Font Elements
Tandelle
Century Gothic
