Page 12 - QSC EE Guide 07-19 Remote
P. 12

Cigna
         Plan Name                                                              HSA PPO

         Network Name                                       Choice Fund OA Plus              Non-Network
         Health Benefits
         Lifetime Maximum Benefit                                               Unlimited
         Calendar Year Deductible
          - Individual                                             $1,500                         $3,000
          - Individual in a Family                                $2,700                          $3,000
          - Family                                                $3,000                          $6,000
         Out-of-Pocket Maximum
          - Individual                                            $3,000                          $6,000
          - Family                                                $6,000                         $12,000
         Coinsurance (You Pay)                                     20%                             50%
         Office Visit Copay
          - Preventive Care                                     No Charge                    Deductible, 50%
          - Primary Care Physician                            Deductible, 20%                Deductible, 50%
          - Specialist                                        Deductible, 20%                Deductible, 50%
          - Urgent Care                                       Deductible, 20%                Deductible, 50%
          - TeleHealth                                          Deductible,                        N/A
                                                              $45-$49 Copay
         Hospitalization
          - Inpatient                                         Deductible, 20%                Deductible, 50%

          - Outpatient Surgery                                Deductible, 20%                Deductible, 50%

         Emergency Services                                                   Deductible, 20%
         Acupuncture                                          Deductible, 20%                Deductible, 50%
                                                                             Max 12 Visits/Year
         Lab and X-Ray
          - Diagnostic                                        Deductible, 20%                Deductible, 50%
          - Complex                                           Deductible, 20%                Deductible, 50%
         Pharmacy Benefits
         Pharmacy Deductible                                 Health Deductible*
         Retail Pharmacy
          - Generic                                        Deductible, $10 Copay
          - Brand Name Formulary                           Deductible, $25 Copay
          - Brand Name Non-Formulary                       Deductible, $50 Copay
          - Supply Limit                                          30 Days
         Mail Order Pharmacy                                                                   Not Covered
          - Generic                                        Deductible, $20 Copay
          - Brand Name Formulary                           Deductible, $50 Copay
          - Brand Name Non-Formulary                       Deductible, $100 Copay
          - Supply Limit                                          90 Days
         Specialty                                             20% Max $250

          - Supply Limit                                          30 Days
         *In-network preventive medications/products are not subject to the deductible.
   7   8   9   10   11   12   13   14   15   16   17