Page 5 - Bobit Benefit Guide 2018 FINAL

Benefits

Medical Insurance CIGNA

Cigna Cigna
HMO PPO

Plan Features HMO or Managed Care Open Access Plus Non-Network
PPO Network
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (calendar year) Excludes Copays Excludes Copays
- Individual $0 $750 $1,500
- Family $0 $1,500 $3,000
Co-Insurance (plan pays) 100% 80% after Deductible 60% after Deductible
Office Visit Copay
- Primary Care Physician $20 Copay $25 Copay 60% after Deductible
- Specialist $40 Copay $40 Copay 60% after Deductible
Advanced Radiology/X-Ray (MRI, CT) $250 $250 $500
Out of Pocket Maximum (calendar year) Includes Copays Includes Ded. & Copays Includes Ded. & Copays
- Individual $3,500 $6,350 $13,500
- Family $7,000 $12,700 $27,000
Hospitalization
- Inpatient $500/Admit $500/Admit, then 80% $1,000/Admit, then 60%
- Outpatient $250/Admit 80% after Deductible 60% after Deductible

Emergency Services $200 $250 Copay, then 80% $500 Copay, then 80%
Urgent Care $100 $125 Copay $125 Copay

Preventive Care 100% 100% Not Covered
Rehab Therapy $40 $40 60% after Deductible
20 Visits Max/Year 20 Visits Max/Year
Chiropractic $10 $40 60% after Deductible

20 Visits Max/Year 20 Visits Max/Year
Mental Health & Substance Abuse
- Inpatient $500/Admit $500/Admit, then 80% $1,000/Admit, then 60%
- Outpatient $40 $40 60% after Deductible
Prescription Drug Benefits

Retail Pharmacy
- Generic Formulary $10 Copay $15 Copay
Non-Network
- Brand Name Formulary $20 Copay $30 Copay
RX Not Covered
- Non-Formulary $40 Copay $50 Copay
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
- Generic Formulary $20 Copay $30 Copay Non-Network
- Brand Name Formulary $40 Copay $60 Copay
RX Not Covered
- Non-Formulary $80 Copay $100 Copay
- Supply Limit 90 Days 90 Days

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