Page 7 - United Capital EE Guide 04-18 PFE

MEDICAL INSURANCE

CIGNA CIGNA
PPO HSA
Network Name Network Non-Network Network Non-Network
HEALTH BENEFITS
Lifetime Maximum Unlimited Unlimited
Annual Deductible
• Individual $500 $1,000 $4,000 $8,000
• Family $1,000 $2,000 $8,000 $16,000
Coinsurance (Plan Pays) 80% 50% 80% 60%
Physician Office Visit
• PCP $25 Copay Deductible, 50% Deductible, 20% Deductible, 40%
• Specialist $50 Copay Deductible, 50% Deductible, 20% Deductible, 40%
• Telehealth $25 Copay N/A Deductible, 20% N/A
Out-of-Pocket Maximum
• Individual $3,000 $6,000 $5,500 $11,000
• Family (Ind Protection*) $6,000 $12,000 $11,000 $22,000
Hospitalization
• Inpatient Deductible, 20% Deductible, 50% Deductible, 20% Deductible, 40%
• Outpatient Surgery Deductible, 20% Deductible, 50% Deductible, 20% Deductible, 40%
Emergency Services $100 Copay Deductible, 20%
Urgent Care $50 Copay Deductible, 50% Deductible, 20% Deductible, 40%
Preventive Care No Charge Deductible, 50% No Charge Deductible, 40%
Chiropractic $25 Copay Deductible, 50% Deductible, 20% Deductible, 40%
30 Visits/Year 30 Visits/Year
PHARMACY BENEFITS
Annual Deductible None Medical Deductible Applies*
Retail Pharmacy
• Generic $10 Copay Not Covered $15 Copay Not Covered
• Preferred Brand $30 Copay Not Covered $20 Copay Not Covered
• Non-Preferred Brand $60 Copay Not Covered $35 Copay Not Covered
• Supply Limit 30 Days N/A 30 Days N/A
Mail Order Pharmacy
• Generic $20 Copay Not Covered $37 Copay Not Covered
• Preferred Brand $60 Copay Not Covered $60 Copay Not Covered
• Non-Preferred Brand $120 Copay Not Covered $105 Copay Not Covered
• Supply Limit 90 Days N/A 90 Days N/A
Specialty
• Retail $100 Copay Not Covered $100 Copay Not Covered
• Mail Order $100 Copay Not Covered $100 Copay Not Covered
• Supply Limit 30 Days N/A 30 Days N/A
*Some preventive drugs are not subject to the medical deductible. See UltiPro for the full list.

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