Page 8 - QSC Benefit Summary 7-18 SO CALIFORNIA

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 (800) HEALTH BENEFITS You Pay You Pay
244-6224 to find a provider near Lifetime Maximum Unlimited
you. Option 2 HMO participants Annual Deductible
should refer to the “Southern CA
Select (St Joseph Hoag Health Individual $1,500 $3,000
Select Plan, Scripps Select Plan, Individual in a Family $2,700 $3,000
HealthCare Partners Select Plan)” Family $3,000 $6,000
plan, Option 3 HMO participants Coinsurance 20% 50%
should refer to the “CIGNA Physician Office Visit
HealthCare of California, Primary Care Physician 20% 50%
Inc. - So. CA HMO/Network” plan Specialist 20% 50%
and PPO/HSA PPO participants Out-of-Pocket Maximum
should refer to the “Open Access Individual $3,000 $6,000
Plus, OA plus, Choice Fund OA Family $6,000 $12,000
Plus” plan when prompted.
Hospitalization
Inpatient 20% 50%
Outpatient Surgery 20% 50%

myCigna Mobile App Emergency Services 20%
If you’re a Cigna member, consider Urgent Care 20% 50%
downloading the myCigna mobile
app for instant access to your Acupuncture 20% 50%
health plan details. myCigna mobile 12 Visits/Year
app provides secure member
information, anytime, anywhere. Preventive Care Ded Waived, 0% 50%
Use it to search for a doctor, urgent Mental Disorders and
care center, or facility. The app is Substance Abuse
convenient, easy-to-use, and free. Inpatient 20% 50%
Outpatient 20% 50%
Use the secure member app where
you’ll have access to: You Pay You Pay
• Cigna’s provider directory PHARMACY BENEFITS
• Coverage details Pharmacy Deductible Health Deductible Applies*
• Deductible expenses Retail (30 Day Supply)
• Account balances Generic Formulary $10 Copay Not Covered
• Claims information Brand Name Formulary $25 Copay Not Covered
• and more Non-Formulary $50 Copay Not Covered

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