Page 8 - QSC Benefits Guide 7-17 CALIFORNIA A

MEDICAL INSURANCE

Cigna
Plan Features Options 1 &2 HMO
So CA Select Network
Network Name OR So CA HMO
HEALTH BENEFITS You Pay
FINDING A MEDICAL Lifetime Maximum Unlimited
PROVIDER: Annual Deductible

Individual None
Go to www.cigna.com or call (800) 244-6224 Family None
to find a provider near you. Option 1 HMO Coinsurance 0%
participants should refer to the “Southern CA
Select (St Joseph Hoag Health Select Plan, Physician Office Visit
Scripps Select Plan, HealthCare Partners Select Primary Care Physician $15 Copay
Plan)” plan, Option 2 HMO participants should Specialist $30 Copay
refer to the “CIGNA HealthCare of California, Out-of-Pocket Maximum
Inc. - So. CA HMO/Network” plan and PPO/ Individual $1,500
HSA PPO participants should refer to the “Open Family $3,000
Access Plus, OA plus, Choice Fund OA Plus” Hospitalization
plan when prompted. Inpatient $250 Copay
Outpatient Surgery $30 Copay
Emergency Services $150 Copay
Urgent Care $35 Copay
Summary of Benefits and
Coverage (SBC) Acupuncture $15 / $30 Copay
Health insurance issuers and group health plans are 12 Visits/Year
required to provide you with an easy-to understand Preventive Care 0%
summary about your health plan’s benefits and
coverage, referred to as a Summary of Benefits and Mental Disorders and
Coverage (SBC). This Employee Benefit Guide is Substance Abuse
designed to help you compare the plan options Inpatient $250 Copay
offered by QSC. Please refer to the SBC and carrier Outpatient $30 Copay
contracts provided by Cigna for additional plan
details. PHARMACY BENEFITS You Pay

Pharmacy Deductible None
Retail Pharmacy
Generic Formulary $10 Copay
Brand Name Formulary $20 Copay
Non-Formulary $40 Copay
Supply Limit 30 Days
Mail Order Pharmacy
Generic Formulary $20 Copay
Brand Name Formulary $40 Copay
Non-Formulary $80 Copay
Supply Limit 90 Days

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