Page 10 - 2020 Dawson Benefits Guide

US Mainland—Medical Plan Details

This plan is only available to U.S. mainland employees.

Cigna Open Access Plus Cigna Open Access Plus Cigna Open Access Plus
Base—$2,000 PPO Choice—$1,000 PPO HDHP 1—$3,000 HDHP
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Embedded Embedded Embedded
Individual $2,000 $4,000 $1,000 $3,000 $3,000 $6,000
Family $4,000 $12,000 $2,000 $6,000 $6,000 $12,000
Out-of-Pocket Maximum (includes deductible)
Individual $6,350 $16,000 $3,000 $9,000 $5,000 $10,000
Family $12,700 $48,000 $6,000 $18,000 $10,000 $20,000
Physician Oice Visits
Preventive Care Covered at 50% Covered at 30% Covered at 100% 40% coinsurance
100% coinsurance 100% coinsurance
Primary Care Visit $35 copay 50% $25 copay 30% 20% coinsurance 40% coinsurance
coinsurance coinsurance
Specialist Visit $50 copay 50% $40 copay 30% 20% coinsurance 40% coinsurance
coinsurance coinsurance
Telemedicine $35 copay Not covered $25 copay Not covered 20% coinsurance Not covered
Urgent Care $75 copay 50% $75 copay 30% 20% coinsurance 40% coinsurance
coinsurance coinsurance
Hospital Services
Inpatient 30% 50% 20% 40% 20% coinsurance 40% coinsurance
coinsurance coinsurance coinsurance coinsurance
Outpatient 30% 50% 20% 40% 20% coinsurance 40% coinsurance
coinsurance coinsurance coinsurance coinsurance
Emergency Room $250 copay $250 copay $250 copay $250 copay 20% coinsurance 40% coinsurance

10 2020 Benefits Guide