Page 12 - QSC EE Guide 01-20 SLO

Cigna
Plan Name HSA PPO

Network Name Open Access Plus Non-Network
Health Benefits
Lifetime Maximum Benefit Unlimited
Calendar Year Deductible
- Individual $1,500 $3,000
- Individual in a Family $2,800 $3,000
- Family $3,000 $6,000
Out-of-Pocket Maximum
- Individual $3,000 $6,000
- Family $6,000 $12,000
Coinsurance (You Pay) 20% 50%
Office Visit Copay
- Preventive Care No Charge Deductible, 50%
- Primary Care Physician Deductible, 20% Deductible, 50%
- Specialist Deductible, 20% Deductible, 50%
- Urgent Care Deductible, 20% Deductible, 50%
- TeleHealth Deductible, N/A
$45-$49 Copay
Hospitalization
- Inpatient Deductible, 20% Deductible, 50%

- Outpatient Surgery Deductible, 20% Deductible, 50%

Emergency Services Deductible, 20%
Acupuncture Deductible, 20% Deductible, 50%
Max 12 Visits/Year
Lab and X-Ray
- Diagnostic Deductible, 20% Deductible, 50%
- Complex Deductible, 20% Deductible, 50%
Pharmacy Benefits
Pharmacy Deductible Health Deductible*
Retail Pharmacy
- Generic Deductible, $10 Copay
- Brand Name Formulary Deductible, $25 Copay
- Brand Name Non-Formulary Deductible, $50 Copay
- Supply Limit 30 Days
Mail Order Pharmacy Not Covered
- Generic Deductible, $20 Copay
- Brand Name Formulary Deductible, $50 Copay
- Brand Name Non-Formulary Deductible, $100 Copay
- Supply Limit 90 Days
Specialty 20% Max $250

- Supply Limit 30 Days
*In-network preventive medications/products are not subject to the deductible.