Page 9 - QSC Benefit Summary 7-18 SO CALIFORNIA

MEDICAL INSURANCE

Cigna Cigna
Plan Features Options 2 & 3 HMO Option 4 OAP PPO
So CA Select Network Open Access Plus
Network Name OR So CA HMO (OAP) Non-Network
HEALTH BENEFITS You Pay You Pay You Pay
Lifetime Maximum Unlimited Unlimited
Annual Deductible
Individual None $750
Individual in a Family None $750
Family None $1,500
Coinsurance 0% 20% 40%
Physician Office Visit Ded Waived
Primary Care Physician $20 Copay $25 Copay 40%
Specialist $40 Copay $40 Copay 40%
Out-of-Pocket Maximum
Individual $2,000 $3,500
Family $4,000 $7,000
Hospitalization
Inpatient $500 Copay 20% $500 Copay, 40%
Outpatient Surgery $40 Copay 20% 40%
Emergency Services $150 Copay Ded Waived, $150 Copay
Urgent Care $35 Copay Ded Waived, 40%
$35 Copay
Acupuncture $20 / $40 Copay $25 Copay 40%
12 Visits/Year 12 Visits/Year
Preventive Care 0% Ded Waived, 0% 40%
Mental Disorders and Substance
Abuse
Inpatient $500 Copay 20% $500 Copay, 40%
Outpatient $20 Copay Ded Waived, 40%
$25 Copay
PHARMACY BENEFITS You Pay You Pay You Pay
Pharmacy Deductible None None

Retail (30 Day Supply)
Generic Formulary $10 Copay $10 Copay Not Covered
Brand Name Formulary $25 Copay $25 Copay Not Covered
Non-Formulary $50 Copay $50 Copay Not Covered
Mail Order (90 Day Supply)
Generic Formulary $20 Copay $20 Copay Not Covered
Brand Name Formulary $50 Copay $50 Copay Not Covered
Non-Formulary $100 Copay $100 Copay Not Covered

Specialty (30 Day Supply) 20% Max $100 Retail 20% Max $250 Not Covered
20% Max $300 Mail Order

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