Page 11 - 11639_2019 Open EnrollmentGuidebook_interactive

MY HEALTH
2019 Medical Plan Options
Cigna
Bronze Plan
Silver Plan
Gold Plan
Plan Benefits*
In-Network
Out-Of-Network
In-Network
Out-Of-Network
In-Network
Out-Of-Network
Deductible
Individual Family
$5,000 $10,000
$10,000 $20,000
$1,500 $3,000
$3,000 $6,000
$500 $1,000
$1,500 $3,000
Medical Coinsurance
20%
50%
30%
50%
20%
50%
Lifetime Maximum
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Office Visits
Specialist Visit*
20% 20%
50% 50%
$30 copay $30 copay
50% 50%
$20 copay $40 copay
50% 50%
Preventive Care
Plan covers 100%
50%
Plan covers 100%
50%
Plan covers 100%
50%
Emergency Care
Hospital ER Urgent Care
20% 20%
20% 20%
30% 30%
30% 30%
20% 20%
20% 20%
Inpatient Hospital
20%
50%
30%
50%
20%
50%
Outpatient Hospital
20%
50%
30%
50%
20%
50%
Mental Health & Substance Abuse
Inpatient* Outpatient*
20% 20%
50% 50%
30% $30 copay
50% 50%
20% $40 copay
50% 50%
Hospital Precertification Required
Doctor Responsible
Associate Responsible**
Doctor Responsible
Associate Responsible**
Doctor Responsible
Associate Responsible**
Total OOPM (Medical & Prescription)
Individual Family
$6,750 $13,500
$13,500 $27,000
$6,750 $13,500
$13,500 $27,000
$6,750 $13,500
$13,500 $27,000
CVS / Caremark
Prescription Coverage
Retail
30-Day Supply
Once deductible is met, you pay
Generic
20%
Not Covered
$25 copay
Not Covered
$15 copay
Not Covered
Preferred Brand
20%
30% (Min:$40,Max:$500)
20% (Min:$30,Max:$500)
Non-Preferred
20%
30% (Min:$60,Max:$500)
20% (Min:$50,Max:$500)
Specialty
20%, to $500
30% (Max:$500)
20% (Max:$500)
Mail Order / Maintenance Choice 90-day Supply
Once deductible is met, you pay
Generic
20%
Not Covered
$45 copay
Not Covered
$25 copay
Not Covered
Preferred Brand
20%
30% (Min:$75,Max:$500)
20% (Min:$55,Max:$500)
Non-Preferred
20%
30% (Min:$115,Max:$500)
20% (Min:$95,Max:$500)
Specialty
20%, to $500
30% (Max:$500)
20% (Max:$500)
* May be subject to certain limitations, separate deductibles, copays, plan limits, or lifetime limits.
** $300 penalty applies for non-compliance.
*** One annual routine mammogram is covered in full at an in-network facility.
**** Benefits may be subject to separate deductibles, copay and limitations. Details about coverage of specific services can be
found in the summary plan description and plan documents.
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Applied Choices – 2019 11