Page 7 - United Capital EE Guide 04-18 PFE

MEDICAL INSURANCE MEDICAL INSURANCE

CIGNA | PPO MEDICAL PLAN CIGNA CIGNA
The Cigna Preferred Provider Organization (PPO) plan allows you to direct your own care. If you receive care from a physician who PPO HSA
is a member of the network, a greater percentage of the entire cost will be paid by the insurance plan, however, you are not limited Network Name Network Non-Network Network Non-Network
to the physicians within the network and you may self-refer to specialists. If you obtain services using a non-network provider, HEALTH BENEFITS
please note that you will be responsible for the difference between the covered amount and the actual charges, and you may be
responsible for filing claims. Lifetime Maximum Unlimited Unlimited
Annual Deductible
• Individual $500 $1,000 $4,000 $8,000
CIGNA | HSA MEDICAL PLAN • Family $1,000 $2,000 $8,000 $16,000

With the HSA plan through Cigna, you can pay for qualified healthcare expenses now and grow your savings for future healthcare Coinsurance (Plan Pays) 80% 50% 80% 60%
needs. This plan combines a High Deductible Health Plan (HDHP) with a special, tax-qualified savings account (HSA). You can Physician Office Visit
contribute tax-free money to your HSA up to IRS maximums. All expenses are subject to the deductible except preventive services. • PCP $25 Copay Deductible, 50% Deductible, 20% Deductible, 40%
The money in your account is yours to pay for current healthcare expenses - or you can save toward future healthcare expenses. • Specialist $50 Copay Deductible, 50% Deductible, 20% Deductible, 40%
Similar to the PPO plan, you have the freedom to choose your doctor without the requirement of selecting a PCP and you may • Telehealth $25 Copay N/A Deductible, 20% N/A
self-refer to specialists. You may use a network provider whose negotiated rates provide richer levels of benefits with claim forms Out-of-Pocket Maximum
filed by the providers. You may also obtain services using a non-network provider; however, you will be responsible for the difference • Individual $3,000 $6,000 $5,500 $11,000
between the covered amount and the actual charges and you may be responsible for filing claims. Additional information on how • Family (Ind Protection*) $6,000 $12,000 $11,000 $22,000
the HSA plan works is located on page 8 of this guide.
Hospitalization
• Inpatient Deductible, 20% Deductible, 50% Deductible, 20% Deductible, 40%
• Outpatient Surgery Deductible, 20% Deductible, 50% Deductible, 20% Deductible, 40%
Emergency Services $100 Copay Deductible, 20%
FINDING A MEDICAL PROVIDER: Urgent Care $50 Copay Deductible, 50% Deductible, 20% Deductible, 40%

Go to www.cigna.com or call (800) 244-6224. Refer to the “PPO, Choice Fund PPO” plan when prompted. Preventive Care No Charge Deductible, 50% No Charge Deductible, 40%
Chiropractic $25 Copay Deductible, 50% Deductible, 20% Deductible, 40%
30 Visits/Year 30 Visits/Year
PHARMACY BENEFITS
BENEFITS HOTLINE Annual Deductible None Medical Deductible Applies*
Cigna provides health advocacy services to help you and your eligible family members resolve many of the complex health care, Retail Pharmacy
health insurance, or medical bill challenges you may face. This service is offered at no charge to you. • Generic $10 Copay Not Covered $15 Copay Not Covered
• Preferred Brand $30 Copay Not Covered $20 Copay Not Covered
Simply call (866) 799-2725 to be assigned a Personal Health Advocate who may help you with: • Non-Preferred Brand $60 Copay Not Covered $35 Copay Not Covered
z Finding a doctor, hospital, second opinion, or diagnostic service • Supply Limit 30 Days N/A 30 Days N/A
z Resolving health coverage issues, medical claims, denials and appeals Mail Order Pharmacy
z Estimating procedure costs and negotiating fees • Generic $20 Copay Not Covered $37 Copay Not Covered
z Locating home care, special services, senior care, or hospice • Preferred Brand $60 Copay Not Covered $60 Copay Not Covered
z Identifying wellness services and alternative medicine • Non-Preferred Brand $120 Copay Not Covered $105 Copay Not Covered
• Supply Limit 90 Days N/A 90 Days N/A
Specialty
• Retail $100 Copay Not Covered $100 Copay Not Covered
• Mail Order $100 Copay Not Covered $100 Copay Not Covered
• Supply Limit 30 Days N/A 30 Days N/A
*Some preventive drugs are not subject to the medical deductible. See UltiPro for the full list.

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