Page 6 - 2015 Four Seasons Sante Fe/Vail Enrollment Guide
P. 6
Medical/Prescription Drug
Medical Insurance
We partner with Cigna to offer you medical insurance. There are two plan options: HSA and the OAPIN Plan. You
can obtain more detailed summary plan descriptions (SPDs) through the My Four Seasons Beneits website.
2015
HSA OAPIN
Deductible (Single/Family)
In-Network $1,500/$3,000 $300/$600
Out-of-Network $3,000/$6,000 N/A
Coinsurance
In-Network 80% 85%
Out-of-Network 60% N/A
Out-of-Pocket Max (includes deductible)
In-Network $3,500/$7,000 $3,000/$6,000
Out-of-Network $7,000/$14,000 N/A
Other
Primary Care Physician (In-Network) Ded/Coinsurance $25
Specialist (In-Network) Ded/Coinsurance $50
Emergency Room Ded/Coinsurance $200
Urgent Care Ded/Coinsurance $75
Rx (In-Network) $5/40/70/100x2 after ded.; once out-of- $5/30/60/
pocket max is met plan pays 100% $90x2
Important Deductible/
Out-of-Pocket Notice New Out of Pocket Maximum Limit for In-Network
for the HSA Plan Services
Under the HSA family plan, the The Affordable Care Act requires a limit on your medical out-of-pocket
individual deductible does not maximum. The medical out-of-pocket limit takes into account all cost-sharing
apply. For example, if you incurred amounts that you pay for medical and prescription drugs under the medical
$2,000 in medical expenses, plan. Deductibles, copays, coinsurance, and similar charges count toward
the plan will not reimburse you your out-of-pocket maximum. However, this does not include charges for
until you, or, other members of non-covered services, amounts you pay for out-of-network claims, provider
your family have accumulated balance-billed amounts, amounts you pay above any reference price,
medical expenses in excess of amounts you pay when you do not receive services at a network location, or
$3,000. network provider speciically designated for your services, or special charges
This applies to the Out-of-Pocket and penalties.
Maximum as well.
Colour Elements
Logo & Logo Variations
My Four Seasons BENEFITS My Four Seasons 6
BENEFITS
Icon Image Elements Font Elements
Tandelle
Century Gothic
Medical Insurance
We partner with Cigna to offer you medical insurance. There are two plan options: HSA and the OAPIN Plan. You
can obtain more detailed summary plan descriptions (SPDs) through the My Four Seasons Beneits website.
2015
HSA OAPIN
Deductible (Single/Family)
In-Network $1,500/$3,000 $300/$600
Out-of-Network $3,000/$6,000 N/A
Coinsurance
In-Network 80% 85%
Out-of-Network 60% N/A
Out-of-Pocket Max (includes deductible)
In-Network $3,500/$7,000 $3,000/$6,000
Out-of-Network $7,000/$14,000 N/A
Other
Primary Care Physician (In-Network) Ded/Coinsurance $25
Specialist (In-Network) Ded/Coinsurance $50
Emergency Room Ded/Coinsurance $200
Urgent Care Ded/Coinsurance $75
Rx (In-Network) $5/40/70/100x2 after ded.; once out-of- $5/30/60/
pocket max is met plan pays 100% $90x2
Important Deductible/
Out-of-Pocket Notice New Out of Pocket Maximum Limit for In-Network
for the HSA Plan Services
Under the HSA family plan, the The Affordable Care Act requires a limit on your medical out-of-pocket
individual deductible does not maximum. The medical out-of-pocket limit takes into account all cost-sharing
apply. For example, if you incurred amounts that you pay for medical and prescription drugs under the medical
$2,000 in medical expenses, plan. Deductibles, copays, coinsurance, and similar charges count toward
the plan will not reimburse you your out-of-pocket maximum. However, this does not include charges for
until you, or, other members of non-covered services, amounts you pay for out-of-network claims, provider
your family have accumulated balance-billed amounts, amounts you pay above any reference price,
medical expenses in excess of amounts you pay when you do not receive services at a network location, or
$3,000. network provider speciically designated for your services, or special charges
This applies to the Out-of-Pocket and penalties.
Maximum as well.
Colour Elements
Logo & Logo Variations
My Four Seasons BENEFITS My Four Seasons 6
BENEFITS
Icon Image Elements Font Elements
Tandelle
Century Gothic
