Page 8 - QSC Benefits Guide 7-17 COLORADO

MEDICAL INSURANCE

Cigna
Plan Features Options 1 HMO
Cigna HealthCare
Network Name of CO 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. HMO participants Coinsurance 0%
should refer to the “CIGNA HealthCare of
Colorado, Inc. – HMO” plan and PPO/HSA PPO Physician Office Visit
participants should refer to the “Open Access Primary Care Physician $15 Copay
Plus, OA plus, Choice Fund OA Plus” plan when Specialist $30 Copay
prompted. Out-of-Pocket Maximum
Individual $1,500
Family $3,000

Hospitalization
Inpatient $250 Copay
Summary of Benefits and Outpatient Surgery $30 Copay
Coverage (SBC) $150 Copay
Health insurance issuers and group health plans are Emergency Services
required to provide you with an easy-to understand Urgent Care $35 Copay
summary about your health plan’s benefits and
coverage, referred to as a Summary of Benefits and Acupuncture $15 / $30 Copay
Coverage (SBC). This Employee Benefit Guide is 12 Visits/Year
designed to help you compare the plan options
offered by QSC. Please refer to the SBC and carrier Preventive Care 0%
contracts provided by Cigna for additional plan Mental Disorders and
details. Substance Abuse
Inpatient $250 Copay
Outpatient $30 Copay

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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