Page 53 - Benefits Summary 2018-2019

HSA

SUMMARY OF BENEFITS Cigna Health and Life Insurance Co.

Hercules Real Estate Services, Inc.
Health Savings Account Open Access Plus
Effective Date: 11/1/2018

General Services In-Network Out-of-Network
After the plan deductible is met, After the plan deductible is met,
Physician office visit – Primary Care Physician
(PCP)/Specialist You pay 0% You pay 30%
Plan pays 100% Plan pays 70%
Cigna Telehealth Connection Services
 Includes charges for the delivery of medical and
health-related consultations via secure After the plan deductible is met,
telecommunications technologies, telephones You pay 0% Not Covered
and internet only when delivered by contracted Plan pays 100%
medical telehealth providers (see details on
myCigna.com)
After the plan deductible is met, After the plan deductible is met,
Urgent care visit You pay 0% You pay 30%
 All services including Lab & X-ray
Plan pays 100% Plan pays 70%
After the plan deductible is met,
Plan pays 100%, no copay, no
Preventive Care You pay 30%
deductible
Plan pays 70%
Lab & X-Ray: Plan pays 100%,
no copay, no deductible
Plan pays 100%, no copay, no All other services:
Preventive Services
deductible After the plan deductible is met,
You pay 30%
Plan pays 70%
After the plan deductible is met,
Plan pays 100%, no copay, no
Immunizations You pay 30%
deductible
Plan pays 70%
After the plan deductible is met, After the plan deductible is met,
Coinsurance You pay 0% You pay 30%
Plan pays 100% Plan pays 70%
Plan year deductible
 Entire Family deductible must be met before
benefits will be paid.
 In-network and out-of-network expenses do not Individual: $3,000 Individual: $6,000
cross accumulate.
 Plan deductible always applies before any Family: $6,000 Family: $12,000
copay or coinsurance.
 This plan includes a combined
Medical/Pharmacy deductible.

11/1/2018
ASO
Health Savings Account Open Access Plus - HSA OAP 11-2018 - 7900133. Version# 12

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