Page 8 - SC Fuels Benefit Guide 2018 TEXAS
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MEDICAL
Cigna
HMO
Network Name HMO Network
HEALTH BENEFITS
Calendar Year Deductible
• Individual $500
• Family $1,000
• Individual Protection Yes
Physician Office Visit
• PCP $20 Copay
• Specialist $30 Copay
Out-of-Pocket Maximum Includes Rx Copays and Medical Deductibles
• Individual $2,000
• Family $6,000
• Individual Protection Yes
Hospitalization
• Inpatient Ded, 10%
• Outpatient Surgery Ded, 10%
Diagnostic X-Ray and Lab No Charge
Emergency Services $150 Copay
Urgent Care $50 Copay
Wellness Exams No Charge
PHARMACY BENEFITS
Prescription Drugs - Copays
• Generic Formulary $10 Copay
• Brand Name Formulary $25 Copay
• Non-Formulary $50 Copay
• Mail Order 2x Copay (90 Days)
EMPLOYEE
CONTRIBUTIONS
Employee Rate Per Paycheck
• Employee Only $75.00
• Employee + Spouse 1 $220.00
• Employee + Child(ren) $190.00
• Employee + Family 1 $300.00
1 Spouses who have other medical coverage available to them through their employer are not eligible to enroll in our plan.
FINDING A MEDICAL HMO PROVIDER:
• Visit www.cigna.com. Click Find a Doctor > Plans through your employer or school > Enter Search
Location > Select a Plan:
• Texas: HMO - CIGNA HealthCare of Texas, Inc. - El Paso
• Texas: HMO - CIGNA HealthCare of Texas, Inc. - Houston
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