Page 7 - 2019-2020 Country Financial Credit Union Benefit Booklet

Medical Plan Summary

Country Financial Credit Union offers a choice of two health care programs for
eligible employees with Bywater. As your health benefits administrator, Bywater
is your go-to contact if you have questions regarding your healthcare benefits
and coverage. Bywater will manage your benefits, verify insurance eligibility,
process and pay your medical claims, and provide customer support for you and
your providers. With Bywater, you are granted access to Cigna’s national
network of doctors and hospitals for your healthcare needs.

Every time you check in for any doctor’s appointment or medical service, present
your Bywater medical ID card to the front desk staff as you would any other insurance card. For best results, it is
always good to make sure the office has a copy of the most current ID card and calls to verify eligibility and benefits.
It’s a quick and painless step with the customer service staff and dedicated Bywater Customer Support number
(855.325.2665). NOTE: If you receive care from a non-participating provider, even when referred, you may be billed
for the difference between the approved amount and the provider’s charge.
Please refer to the Summary in this booklet for limitations and exclusions.

Dependent children can remain on the medical until the end of the month in which they turn 26.

Bywater
(855) 325.2665 / https://online.bywaterbenefits.com/v4/login
In-Network Benefit Level
CORE Plan BUY-UP Plan

Group #: TBD Group #: TBD
Preventive Care Covered 100% In-Network
Please refer to the Benefit Summary for guidelines and further information.
PCP: $30 Copay PCP: $30 Copay
Physician’s Office Visit Specialist: $80 Copay Specialist: $60 Copay

Emergency Room $500 Copay $350 Copay

Urgent Care $50 Copay $50 Copay

Deductible $4,000 Individual / $8,000 Family $1,500 Individual / $3,000 Family

Coinsurance 5% 30%

$7,350 Individual / $14,700 Family $5,000 Individual / $10,000 Family

Annual Out-of- Pocket Maximum All deductibles, copays and coinsurance for In-Network services and Out-of-Network mental health
disorders and substance abuse emergency services apply to the Out-of-Pocket Maximum

Employee Bi-Weekly Pre-Tax Contributions

Employee Only $ 60.13 $ 137.31

Employee + Spouse $ 351.04 $ 505.39

Employee + Child(ren) $ 307.40 $ 450.17
Employee + Family $ 598.30 $ 892.78

Note: This is intended to be an easy-to-read summary (not a contract); the above items are only highlights of the plans. Additional limitations and exclusions may apply
to covered services. For a full description of your coverage, please refer to your Certificate of Coverage. In the event of any inconsistencies with the comparison and the
insurer’s Certificate of Coverage, the Certificate will control.

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