Page 5 - Research Affiliates EE Guide 1-20

Benefits

Medical Insurance

Cigna Cigna
Plan Name PPO HSA
Network Name OAP Non-Network OAP Non-Network
Health Benefits
Lifetime Maximum Unlimited Unlimited

Deductible (Annual)
- Individual $250 $500 $2,800 $5,000
- Family $500 $1,000 $5,000 $10,000
Co-Insurance (Plan Pays) 80%-90% 70%-80% 90% 70%
Office Visit Copay
- Primary Care Physician $10 Copay Deductible, 30% Deductible, 10% Deductible, 30%
- Specialist Office Visit $10 Copay Deductible, 30% Deductible, 10% Deductible, 30%
- Urgent Care $35 Copay Deductible, 30% Deductible, 10% Deductible, 30%
- Telehealth (copay applied to ded)
AmWell $10 Copay Not Covered $49 Not Covered
MD Live $10 Copay Not Covered $45 Not Covered
Preventive Care No Charge Deductible, 30% No Charge Deductible, 30%
Out-of-Pocket Maximum Includes Deductible Includes Deductible Includes Deductible Includes Deductible
- Individual $2,500 $5,000 $4,000 $8,000
- Family $5,000 $10,000 $8,000 $16,000

Hospitalization
- Inpatient Deductible, 10%-20% Deductible, Deductible, 10% Deductible, 30%
$400 Copay, 30%
- Outpatient Deductible, 20% Deductible, Deductible, 10% Deductible, 30%
$400 Copay, 40%
Diagnostic Lab No Charge Deductible, 30% Deductible, 10% Deductible, 30%
Diagnostic X-Ray Deductible, 10% Deductible, 30% Deductible, 10% Deductible, 30%
Emergency Services Deductible, $100 Copay, 10% Deductible, 10%

Chiropractic (Max 20 Visits/Year) $10 Copay Deductible, 30% Deductible, 10% Deductible, 30%
Acupuncture (Max 12 Visits/Year) $10 Copay Deductible, 30% Deductible, 10% Deductible, 30%
Pharmacy Benefits

Pharmacy Deductible $0 N/A Health Plan N/A
Deductible Applies
Retail Pharmacy
- Tier 1 $10 Copay Not Covered Ded, $15 Copay Not Covered
- Tier 2 $20 Copay Not Covered Ded, $20 Copay Not Covered
- Tier 3 $35 Copay Not Covered Ded, $35 Copay Not Covered
- Supply Limit 30 Days N/A 30 Days N/A

Mail Order Pharmacy
- Tier 1 $20 Copay Not Covered Ded, $30 Copay Not Covered
- Tier 2 $50 Copay Not Covered Ded, $40 Copay Not Covered
- Tier 3 $95 Copay Not Covered Ded, $70 Copay Not Covered
- Supply Limit 90 Days N/A 90 Days N/A
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