Page 8 - QSC Benefit Summary 7-18 COLORADO

MEDICAL INSURANCE

Cigna
FINDING A MEDICAL Plan Features Option 1 HSA PPO (Choice Fund)
PROVIDER: Choice Fund
Network Name OA Plus Non-Network
Go to www.cigna.com or call HEALTH BENEFITS You Pay You Pay
(800) 244-6224 to find a Lifetime Maximum Unlimited
provider near you. Option 2 HMO Annual Deductible
participants should refer to the
“Cigna HealthCare of Colorado, Individual $1,500 $3,000
Inc. – HMO” plan and PPO/HSA Individual in a Family $2,700 $3,000
PPO participants should refer to Family $3,000 $6,000
the “Open Access Plus, OA plus, Coinsurance 20% 50%
Choice Fund OA Plus” plan when Physician Office Visit
prompted. Primary Care Physician 20% 50%
Specialist 20% 50%
Out-of-Pocket Maximum
Individual $3,000 $6,000
myCigna Mobile App Family $6,000 $12,000
If you’re a Cigna member, consider Hospitalization
downloading the myCigna mobile Inpatient 20% 50%
app for instant access to your Outpatient Surgery 20% 50%
health plan details. myCigna mobile 20%
app provides secure member Emergency Services
information, anytime, anywhere. Urgent Care 20% 50%
Use it to search for a doctor, urgent
care center, or facility. The app is Acupuncture 20% 50%
convenient, easy-to-use, and free.
12 Visits/Year

Use the secure member app where Preventive Care Ded Waived, 0% 50%
you’ll have access to: Mental Disorders and
• Cigna’s provider directory Substance Abuse
• Coverage details Inpatient 20% 50%
• Deductible expenses Outpatient 20% 50%
• Account balances
• Claims information PHARMACY BENEFITS You Pay You Pay
• and more
Pharmacy Deductible Health Deductible Applies*

Download the myCigna mobile app Retail (30 Day Supply)
for free from the iTunes App Store Generic Formulary $10 Copay Not Covered
or Google Play Store. Please note, Brand Name Formulary $25 Copay Not Covered
you must first register as a member Non-Formulary $50 Copay Not Covered
at www.mycigna.com Mail Order (90 Day Supply)
Generic Formulary $20 Copay Not Covered
Brand Name Formulary $50 Copay Not Covered
Non-Formulary $100 Copay Not Covered
Specialty (30 Day Supply) 20% Max $250 Not Covered
*In-network preventive drugs/products are not subject to the deductible.
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