Page 9 - SC Fuels Benefit Guide 2018 TEXAS

MEDICAL

Cigna Cigna
Traditional PPO HSA Compatible PPO
Network Name PPO Network Non-Network PPO Network Non-Network
HEALTH BENEFITS
Calendar Year Deductible
• Individual $750 $1,500 $1,500 $3,000
• Family $2,250 $4,500 $3,000 $6,000
• Individual Protection Yes Yes No No
Physician Office Visit
• PCP $25 Copay Ded, 40% Ded, 10% Ded, 40%
• Specialist $35 Copay Ded, 40% Ded, 10% Ded, 40%
Out-of-Pocket Maximum Includes Rx Copays and Medical Includes Rx Copays and Medical
Deductibles Deductibles
• Individual $4,000 $7,000 $3,500 $7,000
• Family $12,000 $21,000 $7,000 $14,000
• Individual Protection Yes Yes Yes Yes
Hospitalization
• Inpatient Ded, 20% Ded, $250/Admit, 40% Ded, 10% Ded, 40%
• Outpatient Surgery Ded, 20% Ded, $250/Admit, 40% Ded, 10% Ded, 40%
Diagnostic X-Ray and Lab Ded, 20% Ded, 40% Ded, 10% Ded, 40%
Emergency Services Ded, 20% Ded, 10%
Urgent Care $50 Copay Ded, 10%
Wellness Exams No Charge Ded, 40% No Charge Ded, 40%
PHARMACY BENEFITS

Prescription Drugs - Copays Med Ded Applies
• Generic Formulary $10 Copay Not Covered Ded, $10 Copay Not Covered
• Brand Name Formulary $25 Copay Not Covered Ded, $25 Copay Not Covered
• Non-Formulary $50 Copay Not Covered Ded, $50 Copay Not Covered
• Mail Order 2x Copay (90 Days) Not Covered 2x Copay (90 Days) Not Covered
EMPLOYEE CONTRIBUTIONS
Employee Rate Per Paycheck
• Employee Only $65.00 $48.00
• Employee + Spouse 1 $175.00 $160.00
• Employee + Child(ren) $140.00 $120.00
• Employee + Family 1 $260.00 $220.00
1 Spouses who have other medical coverage available to them through their employer are not eligible to enroll in our plan.

FINDING A MEDICAL PROVIDER:
• Cigna PPO: Visit www.cigna.com. Click Find a Doctor > Plans through your employer or school >
Enter Search Location > Select a Plan:
• OAP - Open Access Plus, OA Plus, Choice Fund OA Plus

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