Page 57 - Benefits Summary 2018-2019

Benefits In-Network Out-of-Network
After the plan deductible is met,
You pay 30%
Plan pays 70%
Organ transplant
 Services paid at network level if performed at Transplant Maximums:
Cigna LifeSOURCE Transplant Network® After the plan deductible is met, Heart - $150,000
Facilities You pay 0% Liver - $230,000
 Travel maximum $10,000 per transplant (only Plan pays 100% Bone Marrow - $130,000
available if using Cigna LifeSOURCE Kidney - $80,000
Transplant Network® facility) Pancreas - $50,000
Kidney/Pancreas - $80,000
Heart/Lung - $185,000
Lung - $185,000
Out-of-area services
 Coverage for services rendered outside a
network area
 ER and Ambulance paid the same as network For all other services
You pay 20%
services Plan pays 80%
 Preventive care services covered at 100% for after the network deductible is met
out of area
 In-network deductible and out-of-pocket
maximums apply
Pharmacy In-Network Out-of-Network
Cost Share and Supply
Med Pharmacy Cost Share Once the medical deductible is Once the medical deductible is
 Retail – up to 90-day supply met then the customer is met then the customer is
(except Specialty up to 30-day supply) responsible for the cost share responsible for the coinsurance
 Home Delivery – up to 90-day supply
(except Specialty up to 30-day supply) Retail (per 30-day supply): Retail:
 If you receive a supply of 34 days or less at Generic: You pay $10 You pay 50%
home delivery (including a Specialty Preferred Brand: You pay $30 Your plan pays 50%
Prescription Drug), the home delivery pharmacy Non-Preferred Brand: You pay
cost share will be adjusted to reflect a 30-day $50 Home Delivery:
supply. Not Covered
Retail (per 90-day supply):
Generic: You pay $30
Preferred Brand: You pay $90
Non-Preferred Brand: You pay
$150

Home Delivery (per 90-day
supply):
Generic: You pay $25
Preferred Brand: You pay $75
Non-Preferred Brand: You pay
$125

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

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