Page 13 - QSC EE Guide 07-19 SLO

Cigna Cigna
Plan Name HMO Full PPO
Network Name HMO Open Access Plus Non-Network
Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited
Calendar Year Deductible
- Individual $0 $1,000 $2,000
- Individual in a Family $0 $1,000 $2,000
- Family $0 $2,000 $4,000
Out-of-Pocket Maximum
- Individual $3,000 $4,000 $6,000
- Family $6,000 $8,000 $12,000
Coinsurance (You Pay) 0% 20% 50%
Office Visit Copay
- Preventive Care No Charge No Charge Deductible, 50%
- Primary Care Physician $30 Copay $30 Copay Deductible, 50%
- Specialist $50 Copay $50 Copay Deductible, 50%
- Urgent Care $50 Copay $50 Copay Deductible, 50%
- TeleHealth $30 Copay $30 Copay N/A
Hospitalization
- Inpatient $500 Copay Deductible, 20% Deductible,
$500 Copay, 50%
- Outpatient Surgery $250 Copay Deductible, 20% Deductible, 50%
Emergency Services $150 Copay $150 Copay

Acupuncture $30 / $50 Copay $30 / $50 Copay Deductible, 50%
Max 12 Visits/Year Max 12 Visits/Year
Lab and X-Ray
- Diagnostic No Charge Deductible, 20% Deductible, 50%
- Complex $100 Copay Deductible, 20% Deductible, 50%
Pharmacy Benefits

Pharmacy Deductible $0 $0
Retail Pharmacy
- Generic $15 Copay $15 Copay
- Brand Name Formulary $30 Copay $30 Copay
- Brand Name Non-Formulary $50 Copay $50 Copay
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
- Generic $30 Copay $30 Copay Not Covered
- Brand Name Formulary $60 Copay $60 Copay
- Brand Name Non-Formulary $100 Copay $100 Copay
- Supply Limit 90 Days 90 Days
Specialty 20% Max $100 Retail, 20% Max $250
20% Max $300 Mail Order
- Supply Limit Retail 30 Days / 30 Days
Mail Order 90 Days