Page 6 - Volcom Benefit Summary 2018 CA

MEDICAL OPTIONS

CIGNA CIGNA CIGNA
Plan Features HMO HSA PPO PPO Buy-Up
Network HMO Network PPO Network Non-Network PPO Network Non-Network
Lifetime Maximum Unlimited Unlimited Unlimited
Annual Deductible
Individual $0 $1,500 $3,500 $750 $1,500
Family (Ind Protection) $0 $3,000 ($2,600) $7,000 ($3,500) $1,500 ($750) $3,000 ($1,500)
Coinsurance (You Pay) N/A 10% 30% 20% 40%
Physician Office Visit Ded Waived
PCP $20 Copay Ded, 10% Ded, 30% $35 Copay Ded, 40%
Specialist $20 Copay Ded, 10% Ded, 30% $35 Copay Ded, 40%
Telemedicine $20 Copay Ded, 10% Not Covered $35 Copay Not Covered
Out-of-Pocket Maximum
Individual $1,500 $2,600 $4,500 $2,500 $5,000
Family $3,000 $5,000 $9,000 $5,000 $10,000
Deductible Included N/A Yes Yes Yes Yes
Hospitalization
Inpatient $500 Copay Ded, 10% Ded, 30% Ded, 20% Ded, 40%
Outpatient Surgery $125 Copay Ded, 10% Ded, 30% Ded, 20% Ded, 40%
Lab and X-Ray No Cost Ded, 10% Ded, 30% Ded, 20% Ded, 40%
Complex $100 Copay Ded, 10% Ded, 30% Ded, 20% Ded, 40%
Emergency Services $150 Copay Ded, 10% $250 Copay
Urgent Care $40 Copay Ded, 10% Ded, 30% Ded Waived Ded, 40%
$125 Copay
Preventive Care No Cost Ded Waived Ded, 30% Ded Waived Ded, 40%
No Cost No Cost
Mental Health
Inpatient $500 Copay Ded, 10% Ded, 30% Ded, 20% Ded, 40%
Outpatient $20 Copay Ded, 10% Ded, 30% $35 Copay Ded, 40%
Prescription Drugs
Retail Pharmacy Ded, then:
- Generic $15 Copay $10 Copay Not Covered $10 Copay Not Covered
- Preferred Brand $30 Copay $30 Copay Not Covered $30 Copay Not Covered
- Non-Preferred Brand $45 Copay $50 Copay Not Covered $50 Copay Not Covered
- Supply Limit 30 Days 30 Days N/A 30 Days N/A
Mail Order Pharmacy Ded, then:
- Generic $30 Copay $25 Copay Not Covered $25 Copay Not Covered
- Preferred Brand $60 Copay $75 Copay Not Covered $75 Copay Not Covered
- Non-Preferred Brand $90 Copay $125 Copay Not Covered $125 Copay Not Covered
- Supply Limit 90 Days 90 Days N/A 90 Days N/A
Self Administered
Injectables 30% Max $150 Copay Applicable Copay Not Covered Applicable Copay Not Covered

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