Page 8 - QSC Benefit Summary 7-18 REMOTE

MEDICAL INSURANCE

Cigna
FINDING A MEDICAL Plan Features Option 1 HSA PPO (Choice Fund)
PROVIDER: Choice Fund
Network Name OA Plus Non-Network
Go to www.cigna.com or call (800) HEALTH BENEFITS You Pay You Pay
244-6224 to find a provider near Lifetime Maximum Unlimited
you. Refer to the “Open Access Annual Deductible
Plus, OA plus, Choice Fund OA
Plus” plan when prompted. Individual $1,500 $3,000
Individual in a Family $2,700 $3,000
Family $3,000 $6,000
Coinsurance 20% 50%
myCigna Mobile App Physician Office Visit
If you’re a Cigna member, consider Primary Care Physician 20% 50%
downloading the myCigna mobile Specialist 20% 50%
app for instant access to your Out-of-Pocket Maximum
health plan details. myCigna mobile $3,000 $6,000
app provides secure member Individual
information, anytime, anywhere. Family $6,000 $12,000
Use it to search for a doctor, urgent Hospitalization
care center, or facility. The app is Inpatient 20% 50%
convenient, easy-to-use, and free. Outpatient Surgery 20% 50%
Emergency Services 20%
Use the secure member app where
you’ll have access to: Urgent Care 20% 50%
• Cigna’s provider directory
• Coverage details Acupuncture 20% 50%
• Deductible expenses 12 Visits/Year
• Account balances Preventive Care Ded Waived, 0% 50%
• Claims information
• and more Mental Disorders and
Substance Abuse
Inpatient 20% 50%
Download the myCigna mobile app 20% 50%
for free from the iTunes App Store Outpatient
or Google Play Store. Please note,
you must first register as a member PHARMACY BENEFITS You Pay You Pay
at www.mycigna.com Pharmacy Deductible Health Deductible Applies*
Retail (30 Day Supply)
Generic Formulary $10 Copay Not Covered
Brand Name Formulary $25 Copay Not Covered
Non-Formulary $50 Copay Not Covered

Mail Order (90 Day Supply)
Generic Formulary $20 Copay Not Covered
Brand Name Formulary $50 Copay Not Covered
Non-Formulary $100 Copay Not Covered
Specialty (30 Day Supply) 20% Max $250 Not Covered
*In-network preventive drugs/products are not subject to the deductible.
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