Page 12 - QSC EE Guide 01-20 CA

Cigna Cigna
Plan Name HSA PPO HMO Select

Network Name Open Access Plus Non-Network Select
Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited
Calendar Year Deductible
- Individual $1,500 $3,000 $0
- Individual in a Family $2,800 $3,000 $0
- Family $3,000 $6,000 $0
Out-of-Pocket Maximum
- Individual $3,000 $6,000 $2,000
- Family $6,000 $12,000 $4,000
Coinsurance (You Pay) 20% 50% 0%
Office Visit Copay
- Preventive Care No Charge Deductible, 50% No Charge
- Primary Care Physician Deductible, 20% Deductible, 50% $20 Copay
- Specialist Deductible, 20% Deductible, 50% $40 Copay
- Urgent Care Deductible, 20% Deductible, 50% $35 Copay
- TeleHealth Deductible, N/A $20 Copay
$45-$49 Copay
Hospitalization
- Inpatient Deductible, 20% Deductible, 50% $500 Copay

- Outpatient Surgery Deductible, 20% Deductible, 50% $40 Copay

Emergency Services Deductible, 20% $150 Copay
Acupuncture Deductible, 20% Deductible, 50% $20 / $40 Copay
Max 12 Visits/Year Max 12 Visits/Year
Lab and X-Ray
- Diagnostic Deductible, 20% Deductible, 50% No Charge
- Complex Deductible, 20% Deductible, 50% $40 Copay
Pharmacy Benefits
Pharmacy Deductible Health Deductible* $0
Retail Pharmacy
- Generic Deductible, $10 Copay $10 Copay
- Brand Name Formulary Deductible, $25 Copay $25 Copay
- Brand Name Non-Formulary Deductible, $50 Copay $50 Copay
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
- Generic Deductible, $20 Copay Not Covered $20 Copay
- Brand Name Formulary Deductible, $50 Copay $50 Copay
- Brand Name Non-Formulary Deductible, $100 Copay $100 Copay
- Supply Limit 90 Days 90 Days
Specialty 20% Max $250 20% Max $100 Retail,
20% Max $300 Mail Order
- Supply Limit 30 Days Retail 30 Days /
Mail Order 90 Days
*In-network preventive medications/products are not subject to the deductible.