Page 6 - Volcom Benefit Summary 2018 Texas

MEDICAL OPTIONS

CIGNA CIGNA
Plan Features HSA PPO PPO Buy-Up
Network PPO Network Non-Network PPO Network Non-Network
Lifetime Maximum Unlimited Unlimited
Annual Deductible
Individual $1,500 $3,500 $750 $1,500
Family (Ind Protection) $3,000 ($2,600) $7,000 ($3,500) $1,500 ($750) $3,000 ($1,500)
Coinsurance (You Pay) 10% 30% 20% 40%
Physician Office Visit Ded Waived
PCP Ded, 10% Ded, 30% $35 Copay Ded, 40%
Specialist Ded, 10% Ded, 30% $35 Copay Ded, 40%
Telemedicine Ded, 10% Not Covered $35 Copay Not Covered
Out-of-Pocket Maximum
Individual $2,600 $4,500 $2,500 $5,000
Family $5,000 $9,000 $5,000 $10,000
Deductible Included Yes Yes Yes Yes
Hospitalization
Inpatient Ded, 10% Ded, 30% Ded, 20% Ded, 40%
Outpatient Surgery Ded, 10% Ded, 30% Ded, 20% Ded, 40%
Lab and X-Ray Ded, 10% Ded, 30% Ded, 20% Ded, 40%
Complex Ded, 10% Ded, 30% Ded, 20% Ded, 40%
Emergency Services Ded, 10% $250 Copay
Urgent Care Ded, 10% Ded, 30% Ded Waived Ded, 40%
$125 Copay
Preventive Care Ded Waived Ded, 30% Ded Waived Ded, 40%
No Cost No Cost
Mental Health
Inpatient Ded, 10% Ded, 30% Ded, 20% Ded, 40%
Outpatient Ded, 10% Ded, 30% $35 Copay Ded, 40%
Prescription Drugs
Retail Pharmacy Ded, then:
- Generic $10 Copay Not Covered $10 Copay Not Covered
- Preferred Brand $30 Copay Not Covered $30 Copay Not Covered
- Non-Preferred Brand $50 Copay Not Covered $50 Copay Not Covered
- Supply Limit 30 Days N/A 30 Days N/A
Mail Order Pharmacy Ded, then:
- Generic $25 Copay Not Covered $25 Copay Not Covered
- Preferred Brand $75 Copay Not Covered $75 Copay Not Covered
- Non-Preferred Brand $125 Copay Not Covered $125 Copay Not Covered
- Supply Limit 90 Days N/A 90 Days N/A
Self Administered Injectables
Applicable Copay Not Covered Applicable Copay Not Covered

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